J Anesth Perioper Med. 2018;5(4):281-292. https://doi.org/10.24015/ebcmed.japm.2018.0116
From the Cardiology Department, The James Cook University Hospital, Middlesbrough, UK.
Correspondence to Dr. Matthew W.P. Jackson at matthew. jackson8@nhs.net or at mwpjackson@gmail.com.
EBCMED ID: ebcmed.japm.2018.0116 DOI: 10.24015/ebcmed.japm.2018.0116
Background
The 30-day mortality following non-cardiac surgery ranges from 2%-6%. Observational studies have suggested myocardial injury following non-cardiac surgery (MINS) and subsequent vascular events are partly responsible.
Methods
Postoperative high-sensitivity troponin I levels were recorded on in-patients undergoing non-cardiac surgery. Positive results (> 17 ng/L) were categorized by the associated pathophysiological process; “secondary” if associated with sepsis, significant perioperative bleeding or prolonged pathological atrial or ventricular tachyarrhythmias and “primary” if not. The 30-day and 6-month mortality data were collected. Multivariate Cox proportional hazard modeling determined independent predictors of 6-month mortality.
Results
Of 387 patients analyzed, 125 (32%) were over 75 years of age; 192 (50%) were male. The 30-day mortality (2.8%) was comparable to the VISION study (1.9%); 30-day mortality following an elevated postoperative troponin was 5.6%, all associated with sepsis. The 6-month mortality overall was 10%; 21% following any postoperative troponin elevation, 8.6% following “primary” events, 36% and 21% following “secondary” events associated with sepsis and bleeding respectively and 3.7% with normal post-operative troponin. 5% of deaths had vascular causes identified; none had an elevated postoperative troponin. Emergency presentation, sepsis, and abnormal renal function independently predicted 6-month mortality with the emergency presentation being the strongest predictor. Troponin levels > 1000 ng/ l (highly suggestive of independently predicting 6-month mortality (P = 0.06)) occurred in 13 patients (3.4% of the entire cohort); the majority of these patients were emergency admissions requiring high-dependency or intensive care unit admission and 9 had evidence of perioperative sepsis. “Primary” elevated post-operative troponins were not independent predictors of mortality.
Conclusion
Postoperative high-sensitivity troponin elevation in patients undergoing noncardiac surgery is associated with 30-day and 6-month mortality. However, early mortality in patients with elevated troponin was largely accounted for by other non-cardiac adverse events; we suggest a mixture of pathophysiological processes are at work rather than solely indicating new vascular events. (Funded by the Regional Innovation Fund of NHS England and the South Tees NHS Foundation Trust Research and Development Fund.)
Article Type
Original Article
Declaration of Interests
The authors have no other potential conflicts of interest for this work.
Acknowledgements
This study was supported by grants from the the Regional Innovation Fund of NHS England and internally by the South Tees NHS Foundation Trust Research and Development Fund.
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