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Meister R, Puelacher C, Glarner N, Gualandro DM, Andersson HA, Pargger M, Huré G, Virant G, Bolliger D, Lampart A, Steiner L, Hidvegi R, Lurati Buse G, Kindler C, Gürke L, Mujagic E, Schaeren S, Clauss M, Lardinois D, Hammerer-Lercher A, Chew M, Mueller C. Prediction of perioperative myocardial infarction/injury in high-risk patients after noncardiac surgery. Eur Heart J Acute Cardiovasc Care 2023; 12:729-739. [PMID: 37548292 PMCID: PMC10655147 DOI: 10.1093/ehjacc/zuad090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
AIMS Perioperative myocardial infarction/injury (PMI) is a surprisingly common yet difficult-to-predict cardiac complication in patients undergoing noncardiac surgery. We aimed to assess the incremental value of preoperative cardiac troponin (cTn) concentration in the prediction of PMI. METHODS AND RESULTS Among prospectively recruited patients at high cardiovascular risk (age ≥65 years or ≥45 years with preexisting cardiovascular disease), PMI was defined as an absolute increase in high-sensitivity cTnT (hs-cTnT) concentration of ≥14 ng/L (the 99th percentile) above the preoperative concentration. Perioperative myocardial infarction/injury was centrally adjudicated by two independent cardiologists using serial measurements of hs-cTnT. Using logistic regression, three models were derived: Model 1 including patient- and procedure-related information, Model 2 adding routinely available laboratory values, and Model 3 further adding preoperative hs-cTnT concentration. Models were also compared vs. preoperative hs-cTnT alone. The findings were validated in two independent cohorts. Among 6944 patients, PMI occurred in 1058 patients (15.2%). The predictive accuracy as quantified by the area under the receiver operating characteristic curve was 0.73 [95% confidence interval (CI) 0.71-0.74] for Model 1, 0.75 (95% CI 0.74-0.77) for Model 2, 0.79 (95% CI 0.77-0.80) for Model 3, and 0.74 for hs-cTnT alone. Model 3 included 10 preoperative variables: age, body mass index, known coronary artery disease, metabolic equivalent >4, risk of surgery, emergency surgery, planned duration of surgery, haemoglobin, platelet count, and hs-cTnT. These findings were confirmed in both independent validation cohorts (n = 722 and n = 966). CONCLUSION Preoperative cTn adds incremental value above patient- and procedure-related variables as well as routine laboratory variables in the prediction of PMI.
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Affiliation(s)
- Rebecca Meister
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Department of Internal Medicine, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Noemi Glarner
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Danielle Menosi Gualandro
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Interdisciplinary Medicine in Cardiology Unit, Cardiology Department, Heart Institute (InCor), University of Sao Paulo Medical School, Av. Dr. Enéas Carvalho de Aguiar, 44, Cerqueira César, 05403-900 São Paulo, Brazil
| | - Henrik A Andersson
- Department of Anaesthesiology and Intensive Care Medicine, Linköping University Hospital, SE-581 83 Linköping, Sweden
| | - Mirjam Pargger
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Gabrielle Huré
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Georgiana Virant
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
| | - Daniel Bolliger
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Andreas Lampart
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Luzius Steiner
- Department of Anaesthesiology, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
- Department of Clinical Research, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Reka Hidvegi
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
- Department of Anaesthesiology, Cantonal Hospital St. Gallen, Rorschacher Str. 95/Haus 03, 9007 St. Gallen, Switzerland
| | - Giovanna Lurati Buse
- Department of Anaesthesiology, University Hospital Dusseldorf, Moorenstr. 5 40225 Düsseldorf, NRW, Germany
| | - Christoph Kindler
- Department of Anaesthesiology, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Aargau, Switzerland
| | - Lorenz Gürke
- Department of Vascular Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Edin Mujagic
- Department of Vascular Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Stefan Schaeren
- Department of Spinal Surgery, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Martin Clauss
- Department of Orthopedics and Center of Musculoskeletal Infections, University Hospital Basel, University Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Didier Lardinois
- Department of Thoracic Surgery, University Hospital Basel, University of Basel, Spitalstrasse 21, 4031 Basel, Basel-Stadt, Switzerland
| | - Angelika Hammerer-Lercher
- Department of Laboratory Medicine, Cantonal Hospital Aarau, Tellstrasse 25, 5001 Aarau, Aargau, Switzerland
| | - Michelle Chew
- Department of Anaesthesiology and Intensive Care Medicine, Linköping University Hospital, SE-581 83 Linköping, Sweden
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Spitalstrasse 2, CH-4031 Basel, Basel-Stadt, Switzerland
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Tveit SH, Myhre PL, Omland T. The clinical importance of high-sensitivity cardiac troponin measurements for risk prediction in non-cardiac surgery. Expert Rev Mol Diagn 2023:1-10. [PMID: 37162108 DOI: 10.1080/14737159.2023.2211267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
INTRODUCTION The global healthcare burden associated with surgery is substantial, with many patients experiencing perioperative complications. Cardiac troponin I and T measured with high-sensitivity assays are cardiac specific biomarkers that associate closely with adverse outcomes in most patient populations. Perioperative physiological stress can induce troponin release from cardiomyocytes, a condition known as perioperative myocardial injury (PMI). PMI is associated with increased risk of poor short- and long-term outcomes, and current European guidelines recommend screening for PMI in at-risk individuals undergoing non-cardiac surgery. AREAS COVERED In this review we summarize current knowledge of the prognostic attributes of cardiac troponins, as well as the challenges associated with their application as biomarkers in the perioperative phase. EXPERT OPINION Measurement of circulating levels of cardiac troponins identify individuals at increased risk of poor postoperative outcomes. Systematic screening of at-risk individuals undergoing non-cardiac surgery will result in a large proportion of patients in need of further diagnostic workup to establish the exact nature of their PMI. The lack of concrete evidence of clinical benefit and the increased cost associated with such a strategy is concerning and underscore the need for further research.
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Affiliation(s)
- Sjur H Tveit
- Department of Anesthesia, Division of Surgery, Akershus University Hospital,Lørenskog, Norway
- K.G. Jebsen Centre for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Peder L Myhre
- K.G. Jebsen Centre for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Torbjørn Omland
- K.G. Jebsen Centre for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
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Kvarda P, Puelacher C, Clauss M, Kuehl R, Gerhard H, Mueller C, Morgenstern M. Perioperative myocardial injury and mortality after revision surgery for orthopaedic device-related infection. Bone Joint J 2022; 104-B:696-702. [PMID: 35638215 DOI: 10.1302/0301-620x.104b6.bjj-2021-1486.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. METHODS We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery. RESULTS In total, 911 consecutive patients were included. The overall perioperative myocardial injury (PMI) rate was 15.4% (n = 140). Septic revision surgery for PJI was associated with a significantly higher PMI rate (43.8% (14/32) vs 14.5% (57/393); p = 0.001) and one-year mortality rate (18.6% (6/32) vs 7.4% (29/393); p = 0.038) compared to aseptic revision or primary arthroplasty. The association with PMI persisted in multivariable analysis with an adjusted odds ratio (aOR) of 4.7 (95% confidence interval (CI) 2.1 to 10.7; p < 0.001), but was not statistically significant for one-year mortality (aOR 1.9 (95% CI 0.7 to 5.4; p = 0.240). PMI rate (15.2% (5/33) vs 14.1% (64/453)) and one-year mortality (15.2% (5/33) vs 9.1% (41/453)) after FRI revision surgery were comparable to aseptic long-bone fracture surgery. CONCLUSION Patients undergoing revision surgery for PJI were at a risk of PMI and death compared to those undergoing aseptic arthroplasty surgery. Screening for PMI and treatment in specialized multidisciplinary units should be considered in major bone and joint infections. Cite this article: Bone Joint J 2022;104-B(6):696-702.
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Affiliation(s)
- Peter Kvarda
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Christian Puelacher
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Richard Kuehl
- University of Basel, Basel, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
| | - Hatice Gerhard
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Christian Mueller
- University of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Basel, Switzerland.,Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
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Gueckel J, Puelacher C, Glarner N, Gualandro DM, Strebel I, Zimmermann T, Arslani K, Hidvegi R, Liffert M, Genini A, Marbot S, Schlaepfer M, Steiner LA, Bolliger D, Lampart A, Gürke L, Kindler C, Schären S, Osswald S, Clauss M, Rikli D, Lurati Buse G, Mueller C; BASEL-PMI Investigators and contributors. Patient- and procedure-related factors in the pathophysiology of perioperative myocardial infarction/injury. Int J Cardiol 2022; 353:15-21. [PMID: 35026340 DOI: 10.1016/j.ijcard.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 11/24/2021] [Accepted: 01/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Perioperative myocardial infarction/injury (PMI) is a frequent, often missed and incompletely understood complication of noncardiac surgery. The aim of this study was to evaluate whether patient- or procedure-related factors are more strongly associated to the development of PMI in patients undergoing repeated noncardiac surgery. METHODS In this prospective observational study, patient- and procedure-related factors were evaluated for contribution to PMI using: 1) logistic regression modelling with PMI as primary endpoint, 2) evaluation of concordance of PMI occurrence in the first and the second noncardiac surgery (surgery 1 and 2). and 3) the correlation of the extent of cardiomyocyte injury quantified by high-sensitivity cardiac troponin T between surgery 1 and 2. The secondary endpoint was all-cause mortality associated with PMI reoccurrence in surgery 2. RESULTS Among 784 patients undergoing repeated noncardiac surgery (in total 1'923 surgical procedures), 116 patients (14.8%) experienced PMI during surgery 1. Among these, PMI occurred again in surgery 2 in 35/116 (30.2%) patients. However, the vast majority of patients developing PMI during surgery 2 (96/131, 73.3%) had not developed PMI during surgery 1 (phi-coefficient 0.150, p < 0.001). The correlation between the extent of cardiomyocyte injury occurring during surgery 1 and 2 was 0.153. All-cause mortality following a second PMI in surgery 2 was dependent on time since surgery (adjusted hazard ratio 5.6 within 30 days and 2.4 within 360 days). CONCLUSIONS In high-risk patients, procedural factors are more strongly associated with occurrence of PMI than patient factors, but patient factors are also contributors to the occurrence of PMI.
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Roth S, Huhn R, Jung C, Polzin A, De Hert S, Lurati Buse G. [Cardiac biomarkers in noncardiac surgery patients : Review of cardiac biomarkers for risk stratification and detection of postoperative adverse cardiac events]. Med Klin Intensivmed Notfmed 2021. [PMID: 33564901 DOI: 10.1007/s00063-021-00788-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/18/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Yearly, more than 200 million people worldwide undergo noncardiac surgery of whom about 5% will suffer adverse cardiac events. Therefore, risk stratification and early detection of these events is crucial. OBJECTIVES The goal of this review is to summarize the currently available evidence on the role of biomarkers in perioperative cardiac risk assessment. It presents current data of the established biomarkers troponin and brain natriuretic peptide (BNP), and it also reports on new biomarkers that are still under evaluation, e.g. copeptin (a marker of neurohumoral activation) and presepsin (an inflammation marker). MATERIALS AND METHODS Narrative review. RESULTS AND CONCLUSION According to currently available data, there is a strong association between preoperative troponin or BNP values and postoperative adverse cardiac events and mortality. However, to date, there is only a weak recommendation for routine measurement of these biomarkers even in high-risk patients because the evidence on outcome improvement is still very limited. The evidence on treatment options in case of increased postoperative troponin values is also scarce so that international guidelines come to different conclusions regarding postoperative measurement of toponin. Meanwhile, several new biomarkers are under evaluation.
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Xie J, Qiu L, Tao Y, Zhu T. Perioperative myocardial injury after noncardiac surgery: An easily ignored and challenging problem. Int J Cardiol 2019; 292:42. [PMID: 31349943 DOI: 10.1016/j.ijcard.2019.04.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 04/18/2019] [Indexed: 10/26/2022]
Affiliation(s)
- J Xie
- Department of Cardiology, Shengzhou People's Hospital, The First Affiliated Hospital of Zhejiang University Shengzhou Branch, Shengzhou City, Zhejiang Province 312400, China
| | - L Qiu
- Department of Cardiology, Shengzhou People's Hospital, The First Affiliated Hospital of Zhejiang University Shengzhou Branch, Shengzhou City, Zhejiang Province 312400, China
| | - Y Tao
- Department of Cardiology, Shengzhou People's Hospital, The First Affiliated Hospital of Zhejiang University Shengzhou Branch, Shengzhou City, Zhejiang Province 312400, China.
| | - T Zhu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No. 139 Middle Renmin Road, Furong District, Changsha City, Hunan Province 410011, China
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Toda H, Nakamura K, Nakagawa K, Watanabe A, Miyoshi T, Nishii N, Shimizu K, Hayashi M, Morita H, Morimatsu H, Ito H. Diastolic Dysfunction Is a Risk of Perioperative Myocardial Injury Assessed by High-Sensitivity Cardiac Troponin T in Elderly Patients Undergoing Non-Cardiac Surgery. Circ J 2018; 82:775-782. [PMID: 29151453 DOI: 10.1253/circj.cj-17-0747] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND High-sensitivity cardiac troponin T (hs-cTnT) is useful for detecting myocardial injury and is expected to become a prognostic marker in patients undergoing non-cardiac surgery. The aim of this pilot study evaluating the efficacy of β-blocker therapy in a perioperative setting (MAMACARI study) was to assess perioperative myocardial injury (PMI) in elderly patients with preserved ejection fraction (EF) undergoing non-cardiac surgery.Methods and Results:In this prospective observational cohort study of 151 consecutive patients with preserved EF and aged >60 years who underwent non-cardiac surgery, serum levels of hs-cTnT were measured before and on postoperative days 1 and 3 after surgery. PMI was defined as postoperative hs-cTnT >0.014 ng/mL and relative hs-cTnT change ≥20%. A total of 36 (23.8%) of the patients were diagnosed as having PMI. The incidence of a composite of cardiovascular events within 30 days after surgery, including myocardial infarction, stroke, worsening heart failure, atrial fibrillation and pulmonary embolism, was significantly higher in patients with PMI than in patients without PMI (odds ratio (OR) 9.25, P<0.001, 95% confidence interval (CI) 2.65-32.3). Multivariate analysis revealed that left ventricular diastolic dysfunction defined by echocardiography was independently associated with PMI (OR: 3.029, 95% CI: 1.341-6.84, P=0.008). CONCLUSIONS PMI is frequently observed in elderly patients undergoing non-cardiac surgery. Diastolic dysfunction is an independent predictor of PMI.
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Affiliation(s)
- Hironobu Toda
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Atsuyuki Watanabe
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Toru Miyoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Nobuhiro Nishii
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kazuyoshi Shimizu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Masao Hayashi
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morita
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences.,Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Morimatsu
- Department of Anesthesiology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
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