Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery

P. J. Devereaux; Bruce M. Biccard; Alben Sigamani; Denis Xavier; Matthew T.V. Chan; Sadeesh K. Srinathan; Michael Walsh; Valsa Abraham; Rupert Pearse; C. Y. Wang; Daniel I. Sessler; Andrea Kurz; Wojciech Szczeklik; Otavio Berwanger; Juan Carlos Villar; German Malaga; Amit X. Garg; Clara K. Chow; Gareth Ackland; Ameen Patel; Flavia Kessler Borges; Emilie P. Belley-Cote; Emmanuelle Duceppe; Jessica Spence; Vikas Tandon; Colin Williams; Robert J. Sapsford; Carisi A. Polanczyk; Maria Tiboni; Pablo Alonso-Coello; Atiya Faruqui; DIane Heels-Ansdell; Andre Lamy; Richard Whitlock; Yannick LeManach; Pavel S. Roshanov; Michael McGillion; Peter Kavsak; Matthew J. McQueen; Lehana Thabane; Reitze N. Rodseth; Giovanna A.Lurati Buse; Mohit Bhandari; Ignacia Garutti; Michael J. Jacka; Holger J. Schünemann; Olga Luciá Cortes; Pierre Coriat; Nazari Dvirnik; Fernando Botto; Shirley Pettit; Allan S. Jaffe; Gordon H. Guyatt

doi:10.1001/jama.2017.4360

Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery

P. J. Devereaux, Bruce M. Biccard, Alben Sigamani, Denis Xavier, Matthew T.V. Chan, Sadeesh K. Srinathan, Michael Walsh, Valsa Abraham, Rupert Pearse, C. Y. Wang, Daniel I. Sessler, Andrea Kurz, Wojciech Szczeklik, Otavio Berwanger, Juan Carlos Villar, German Malaga, Amit X. Garg, Clara K. Chow, Gareth Ackland, Ameen PatelFlavia Kessler Borges, Emilie P. Belley-Cote, Emmanuelle Duceppe, Jessica Spence, Vikas Tandon, Colin Williams, Robert J. Sapsford, Carisi A. Polanczyk, Maria Tiboni, Pablo Alonso-Coello, Atiya Faruqui, DIane Heels-Ansdell, Andre Lamy, Richard Whitlock, Yannick LeManach, Pavel S. Roshanov, Michael McGillion, Peter Kavsak, Matthew J. McQueen, Lehana Thabane, Reitze N. Rodseth, Giovanna A.Lurati Buse, Mohit Bhandari, Ignacia Garutti, Michael J. Jacka, Holger J. Schünemann, Olga Luciá Cortes, Pierre Coriat, Nazari Dvirnik, Fernando Botto, Shirley Pettit, Allan S. Jaffe, Gordon H. Guyatt

Cardiovascular Medicine

Research output: Contribution to journal › Article › peer-review

275 Scopus citations

Abstract

IMPORTANCE Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality andmyocardial 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.

Original language	English (US)
Pages (from-to)	1642-1651
Number of pages	10
Journal	JAMA - Journal of the American Medical Association
Volume	317
Issue number	16
DOIs	https://doi.org/10.1001/jama.2017.4360
State	Published - Apr 25 2017

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General Medicine

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10.1001/jama.2017.4360

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Devereaux, P. J., Biccard, B. M., Sigamani, A., Xavier, D., Chan, M. T. V., Srinathan, S. K., Walsh, M., Abraham, V., Pearse, R., Wang, C. Y., Sessler, D. I., Kurz, A., Szczeklik, W., Berwanger, O., Villar, J. C., Malaga, G., Garg, A. X., Chow, C. K., Ackland, G., ... Guyatt, G. H. (2017). Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery. JAMA - Journal of the American Medical Association, 317(16), 1642-1651. https://doi.org/10.1001/jama.2017.4360

Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery. / Devereaux, P. J.; Biccard, Bruce M.; Sigamani, Alben et al.
In: JAMA - Journal of the American Medical Association, Vol. 317, No. 16, 25.04.2017, p. 1642-1651.

Research output: Contribution to journal › Article › peer-review

Devereaux, PJ, Biccard, BM, Sigamani, A, Xavier, D, Chan, MTV, Srinathan, SK, Walsh, M, Abraham, V, Pearse, R, Wang, CY, Sessler, DI, Kurz, A, Szczeklik, W, Berwanger, O, Villar, JC, Malaga, G, Garg, AX, Chow, CK, Ackland, G, Patel, A, Borges, FK, Belley-Cote, EP, Duceppe, E, Spence, J, Tandon, V, Williams, C, Sapsford, RJ, Polanczyk, CA, Tiboni, M, Alonso-Coello, P, Faruqui, A, Heels-Ansdell, DI, Lamy, A, Whitlock, R, LeManach, Y, Roshanov, PS, McGillion, M, Kavsak, P, McQueen, MJ, Thabane, L, Rodseth, RN, Buse, GAL, Bhandari, M, Garutti, I, Jacka, MJ, Schünemann, HJ, Cortes, OL, Coriat, P, Dvirnik, N, Botto, F, Pettit, S, Jaffe, AS & Guyatt, GH 2017, 'Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery', JAMA - Journal of the American Medical Association, vol. 317, no. 16, pp. 1642-1651. https://doi.org/10.1001/jama.2017.4360

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title = "Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery",

abstract = "IMPORTANCE Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality andmyocardial 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.",

author = "Devereaux, {P. J.} and Biccard, {Bruce M.} and Alben Sigamani and Denis Xavier and Chan, {Matthew T.V.} and Srinathan, {Sadeesh K.} and Michael Walsh and Valsa Abraham and Rupert Pearse and Wang, {C. Y.} and Sessler, {Daniel I.} and Andrea Kurz and Wojciech Szczeklik and Otavio Berwanger and Villar, {Juan Carlos} and German Malaga and Garg, {Amit X.} and Chow, {Clara K.} and Gareth Ackland and Ameen Patel and Borges, {Flavia Kessler} and Belley-Cote, {Emilie P.} and Emmanuelle Duceppe and Jessica Spence and Vikas Tandon and Colin Williams and Sapsford, {Robert J.} and Polanczyk, {Carisi A.} and Maria Tiboni and Pablo Alonso-Coello and Atiya Faruqui and DIane Heels-Ansdell and Andre Lamy and Richard Whitlock and Yannick LeManach and Roshanov, {Pavel S.} and Michael McGillion and Peter Kavsak and McQueen, {Matthew J.} and Lehana Thabane and Rodseth, {Reitze N.} and Buse, {Giovanna A.Lurati} and Mohit Bhandari and Ignacia Garutti and Jacka, {Michael J.} and Sch{\"u}nemann, {Holger J.} and Cortes, {Olga Luci{\'a}} and Pierre Coriat and Nazari Dvirnik and Fernando Botto and Shirley Pettit and Jaffe, {Allan S.} and Guyatt, {Gordon H.}",

note = "Publisher Copyright: {\textcopyright} 2017 American Medical Association.",

year = "2017",

month = apr,

day = "25",

doi = "10.1001/jama.2017.4360",

language = "English (US)",

volume = "317",

pages = "1642--1651",

journal = "JAMA - Journal of the American Medical Association",

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TY - JOUR

T1 - Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery

AU - Devereaux, P. J.

AU - Biccard, Bruce M.

AU - Sigamani, Alben

AU - Xavier, Denis

AU - Chan, Matthew T.V.

AU - Srinathan, Sadeesh K.

AU - Walsh, Michael

AU - Abraham, Valsa

AU - Pearse, Rupert

AU - Wang, C. Y.

AU - Sessler, Daniel I.

AU - Kurz, Andrea

AU - Szczeklik, Wojciech

AU - Berwanger, Otavio

AU - Villar, Juan Carlos

AU - Malaga, German

AU - Garg, Amit X.

AU - Chow, Clara K.

AU - Ackland, Gareth

AU - Patel, Ameen

AU - Borges, Flavia Kessler

AU - Belley-Cote, Emilie P.

AU - Duceppe, Emmanuelle

AU - Spence, Jessica

AU - Tandon, Vikas

AU - Williams, Colin

AU - Sapsford, Robert J.

AU - Polanczyk, Carisi A.

AU - Tiboni, Maria

AU - Alonso-Coello, Pablo

AU - Faruqui, Atiya

AU - Heels-Ansdell, DIane

AU - Lamy, Andre

AU - Whitlock, Richard

AU - LeManach, Yannick

AU - Roshanov, Pavel S.

AU - McGillion, Michael

AU - Kavsak, Peter

AU - McQueen, Matthew J.

AU - Thabane, Lehana

AU - Rodseth, Reitze N.

AU - Buse, Giovanna A.Lurati

AU - Bhandari, Mohit

AU - Garutti, Ignacia

AU - Jacka, Michael J.

AU - Schünemann, Holger J.

AU - Cortes, Olga Luciá

AU - Coriat, Pierre

AU - Dvirnik, Nazari

AU - Botto, Fernando

AU - Pettit, Shirley

AU - Jaffe, Allan S.

AU - Guyatt, Gordon H.

PY - 2017/4/25

Y1 - 2017/4/25

N2 - IMPORTANCE Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality andmyocardial 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.

AB - IMPORTANCE Little is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality andmyocardial 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.

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Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery

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