Vascular surgery patients: Perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation

Aims: The objectives of this study are to evaluate the prognostic role of pre-operative stratification in patients undergoing elective major vascular surgery, the timing of adverse outcomes, and the predictive role of troponin (cTn). Methods and results: Consecutive vascular surgery candidates (n = 391) were prospectively stratified and treated according to the ACC/AHA guidelines. The patients were categorized into three groups: (1) with coronary revascularization in the past 5 years, (2) with intermediate clinical risk predictors, and (3) with minor or no clinical risk predictors. cTnI was measured post-operatively. By 18 months, 18.7% of subjects had experienced death or acute myocardial infarction (MI) (by the ACC/ESC criteria). The hazard ratio (HR) was 5.21 (95% CI = 2.60-10.43; P < 0.0001) in group 1 and 2.58 (95% CI = 1.27-4.38; P = 0.004) in group 2 when compared with group 3. Most events occurred within 30 days. Elevations of cTnI were associated with adverse outcomes even after multivariable adjustment at long-term (adjusted overall HR = 4.73, 95% CI = 2.92-7.65; P<0.0001) and at 30 days (adjusted HR = 5.52, 95%CI = 3.23-9.42; P < 0.0001). Conclusion: After pre-operative stratification, patients undergoing elective major vascular surgery remain at high risk of MI and death. Events occur mainly early after surgery. cTnI elevations are frequent and independently associated with increased risk. These findings suggest the need for a major re-evaluation of our approach to these patients.