Perioperative myocardial necrosis in patients at high cardiovascular risk undergoing elective non-cardiac surgery
- 1Department of Cardiology, Concord Repatriation General Hospital, University of Sydney, Concord, New South Wales, Australia
- 2Department of Biochemistry, Concord Repatriation General Hospital, University of Sydney, Concord, New South Wales, Australia
- Correspondence to Professor David B Brieger Department of Cardiology, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2139, Australia;
Contributors All authors contributed equally to the conception, design, data collection and analysis and reporting of data. RFA drafted the manuscript which was reviewed and edited by all other authors. All authors approved the final manuscript.
- Accepted 4 March 2012
Objective Cardiovascular complications are important causes of morbidity and mortality in elective non-cardiac surgery. Although difficult to diagnose, perioperative myocardial infarction (MI) remains prognostically important. High-sensitivity troponin T (hs-TnT) assays allow detection of very minor damage to cardiac muscle. These assays are yet to be fully evaluated in the perioperative setting. Our aim was to determine the incidence and predictors of myocardial necrosis in patients at high cardiovascular risk undergoing elective non-cardiac surgery using hs-TnT.
Design Prospective observational cohort study.
Patients 352 consecutive patients undergoing elective major non-cardiac surgery prescribed antiplatelet therapy for primary or secondary cardiovascular event prevention.
Main outcome measure The incidence of elevated preoperative hs-TnT (≥14 ng/litre), hs-TnT-defined perioperative myocardial necrosis (≥ 14ng/litre and 50% increase from preoperative level), and perioperative MI were determined in relation to patient and surgical factors.
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 orthopaedic 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 Perioperative myocardial damage occurs frequently in patients undergoing elective non-cardiac surgery, although the majority of events are clinically undetected. Age and intraoperative hypotension are independent predictors of myocardial necrosis in this setting.
- Elective non-cardiac surgery
- high-sensitivity troponin
- myocardial necrosis
- coronary intervention (PCI)
- acute coronary syndrome
- stable angina
- cardiac function
- heart failure treatment
- left ventricular assist device
- diabetic heart disease
Relationship with industry: The high-sensitivity troponin T assays were provided by Roche Diagnostics.
Funding Dr RFA is supported in part by an unrestricted research grant from the University of Sydney.
Competing interests None.
Ethics approval Ethics approval was approved by Sydney South West Area Health Service Ethics Committee.
Provenance and peer review Not commissioned; internally peer reviewed.