Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization

TY - JOUR

T1 - Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization

AU - Puelacher, Christian

AU - Lurati Buse, Giovanna

AU - Seeberger, Daniela

AU - Sazgary, Lorraine

AU - Marbot, Stella

AU - Lampart, Andreas

AU - Espinola, Jaqueline

AU - Kindler, Christoph

AU - Hammerer, Angelika

AU - Seeberger, Esther

AU - Strebel, Ivo

AU - Wildi, Karin

AU - Twerenbold, Raphael

AU - du Fay de Lavallaz, Jeanne

AU - Steiner, Luzius

AU - Gurke, Lorenz

AU - Breidthardt, Tobias

AU - Rentsch, Katharina

AU - Buser, Andreas

AU - Gualandro, Danielle M

AU - Osswald, Stefan

AU - Mueller, Christian

AU - BASEL-PMI Investigators

N1 - © 2017 The Authors.

PY - 2018/3/20

Y1 - 2018/3/20

N2 - BACKGROUND: Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening.METHODS: We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of ≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did.RESULTS: From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (P<0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7; P=0.684).CONCLUSIONS: PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short- and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do.CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

AB - BACKGROUND: Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening.METHODS: We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of ≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did.RESULTS: From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (P<0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7; P=0.684).CONCLUSIONS: PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short- and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do.CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

KW - Aged

KW - Aged, 80 and over

KW - Biomarkers/blood

KW - Early Diagnosis

KW - Electrocardiography

KW - Female

KW - Heart Diseases/blood

KW - Humans

KW - Incidence

KW - Male

KW - Myocardium/metabolism

KW - Predictive Value of Tests

KW - Prospective Studies

KW - Risk Assessment

KW - Risk Factors

KW - Surgical Procedures, Operative/adverse effects

KW - Switzerland/epidemiology

KW - Time Factors

KW - Tissue Survival

KW - Treatment Outcome

KW - Troponin T/blood

U2 - 10.1161/CIRCULATIONAHA.117.030114

DO - 10.1161/CIRCULATIONAHA.117.030114

M3 - SCORING: Journal article

C2 - 29203498

VL - 137

SP - 1221

EP - 1232

JO - CIRCULATION

JF - CIRCULATION

SN - 0009-7322

IS - 12

ER -