Perioperative Myocardial Necrosis in Patients at High Cardiovascular Risk Undergoing Elective Non-Cardiac Surgery

Study Questions:

What are the incidence and predictors of myocardial necrosis in patients at high cardiovascular risk undergoing elective noncardiac surgery using high-sensitivity troponin T (hs-TnT)?

Methods:

This was a prospective observational cohort study. A total of 352 consecutive patients undergoing elective major noncardiac surgery prescribed antiplatelet therapy for primary or secondary cardiovascular event prevention were included in the analysis. The primary outcome was the incidence of elevated preoperative hs-TnT (≥14 ng/L), hs-TnT-defined perioperative myocardial necrosis (≥14 ng/L and 50% increase from preoperative level), and perioperative myocardial infarction (MI) in relation to patient and surgical factors. Predictors of both baseline elevated hs-TnT and perioperative myocardial necrosis were identified using binary logistic regression and the relationship expressed as an odds ratio [OR] (95% confidence interval).

Results:

Preoperative hs-TnT was elevated in 31%, and postoperative myocardial necrosis occurred in 22% of patients. Predictors of elevated baseline hs-TnT included age (OR, 1.10; p < 0.001), male gender (OR, 2.91; p < 0.001), diabetes requiring insulin therapy (OR, 4.85; p = 0.004), and chronic kidney disease (OR, 3.60; p < 0.001). Independent predictors of perioperative myocardial necrosis were age (OR, 1.07; p < 0.001), intraoperative hypotension (OR, 3.67; p = 0.001), and orthopedic surgery (OR, 2.46; p = 0.005). Only 2% of patients suffered clinically apparent MI. Elevated preoperative hs-TnT did not predict perioperative myocardial necrosis or MI.

Conclusions:

The authors concluded that perioperative myocardial damage occurs frequently in patients undergoing elective noncardiac surgery, although the majority of events are clinically undetected.

Perspective:

This prospective cohort study of patients at high cardiovascular risk undergoing elective noncardiac surgery suggests that perioperative myocardial necrosis occurred frequently and was clinically undetected in the majority of cases. However, hs-TnT-defined myocardial necrosis did not result in any hospital mortality. Independent predictors of myocardial necrosis included increasing age, intraoperative hypotension, and orthopedic surgical procedures. Supply and demand mismatch may play an important role in cardiac troponin release in this setting mediated through intraoperative hypotension. These findings highlight the need for comprehensive preoperative specialist assessment, and underscore the importance of careful intraoperative hemodynamic monitoring and optimization.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: Incidence, Myocardial Infarction, Biological Markers, Cardiovascular Diseases, Troponin T, Hypotension, Risk Factors, Cardiac Surgical Procedures, Hemodynamics, Renal Insufficiency, Chronic, Troponin


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