High sensitivity troponin T concentrations in patients undergoing noncardiac surgery: A prospective cohort study

doi:10.1016/j.clinbiochem.2011.05.017

Clinical Biochemistry

Volume 44, Issue 12, August 2011, Pages 1021-1024

https://doi.org/10.1016/j.clinbiochem.2011.05.017 Get rights and content

Abstract

Objectives

To determine the proportion of noncardiac surgery patients exceeding the published 99th percentile or change criteria with the high sensitivity Troponin T (hs-TnT) assay.

Design and methods

We measured hs-TnT preoperatively and postoperatively on days 1, 2 and 3 in 325 adults.

Results

Postoperatively 45% (95% CI: 39–50%) of patients had hs-TnT ≥ 14 ng/L and 22% (95% CI:17–26%) had an elevation (≥ 14 ng/L) and change (> 85%) in hs-TnT.

Conclusion

Further research is needed to inform the optimal hs-TnT threshold and change in this setting.

Introduction

Noncardiac surgery has made substantial advances in treating diseases and improving patients' quality of life; however, it is also associated with major vascular complications [1]. The Vascular events In noncardiac Surgery patIents cOhort evaluation (i.e., VISION) Study is a large (i.e., 40,000 patient) international prospective cohort study evaluating major vascular complications in a representative sample of patients ≥ 45 years of age undergoing noncardiac surgery. At the beginning of the study, all sites were using the 4th generation troponin T (hence referred to as TnT) assay, but with the 5th generation high sensitivity TnT (hence referred to as hs-TnT) assay gaining regulatory approval there will be a shift to using hs-TnT in this population. The characteristics of the hs-TnT assay in this population are unknown.

Recent publications have reported the analytical characteristics of hs-TnT assay with respect to the 99th percentile (≥ 14 ng/L) in a healthy population, the reference change values (RCVs; > 85%), and the optimal change criteria to identify non-ST segment elevation myocardial infarction (NSTEMI; > 242%) [2], [3], [4]. The PEACE Study demonstrated that 11% of patients with stable coronary artery disease exceeded an hs-TnT assay value ≥ 14 ng/L and that this value was an independent predictor of cardiovascular death [5]. Questions persist, however, regarding whether the reference interval from a healthy population should be applied to all patient populations in all settings [6]. We sought to determine the prevalence of patients exceeding the published 99th percentile versus the derived reference intervals from the preoperative samples from a substudy of VISION patients. We also assessed the different change criteria (85% versus 242%).

Section snippets

Study population

The VISION Bio-bank Study is a substudy of VISION, and includes a prospective sample of VISION patients who are ≥ 45 years of age, undergoing elective or emergent noncardiac surgery requiring overnight hospital admission, and receiving a general or regional anesthetic. Recruitment into the VISION Bio-bank Study has occurred at the following three Canadian hospitals: the Hamilton Health Sciences, Hamilton, Ontario, Saint Joseph's Healthcare, Hamilton, Ontario, and Winnipeg Health Sciences Centre,

Results

The mean (SD) patient age was 65 (11) years, approximately half were female, and there was representation of all major surgical interventions, Table 1. The Revised Cardiac Risk Index suggested that the majority of participants were considered low-risk (i.e., scores of 0 or 1) for a major perioperative vascular complication.

The hs-TnT concentrations were higher postoperatively (days 1, 2, 3) as compared to the preoperative concentrations (Table 1). Preoperatively, 21% (95% CI: 17–25%) of the

Discussion

Our study demonstrates that patients undergoing noncardiac surgery represent a population with significant hs-TnT elevations. Using the published 99th percentile of ≥ 14 ng/L, one in five adults exceeded this threshold prior to surgery. This positive rate increased postoperatively with over 40% of subjects having a postoperative hs-TnT concentration ≥ 14 ng/L. Some authors advocate the need for a change in concentration beyond surpassing a hs-TnT threshold. When both of these criteria are employed

Acknowledgments

Funding and support for this study was obtained via grants from the CANadian Network and Centre for Trials Internationally (CANNeCTIN), Canadian Institutes of Health Research, the Heart and Stroke Foundation of Ontario, Diagnostic Services of Manitoba, and Roche Diagnostics

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Identification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefit over the Revised Cardiac Risk Index
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Citation Excerpt :
Although there is a general consensus favouring the high-sensitivity troponin assays, various definitions and cut-off values have been applied in previous studies. Elevations in preoperative cTns also occur commonly1–5,8,12 and may portend significant morbidity and mortality postoperatively.3,8,12–17 This raises concerns for preoperative risk stratification and a potential dilemma for the management of these patients before surgery.
Patients with perioperative myocardial injury are at risk of death and major adverse cardiovascular and cerebrovascular events (MACCE). The primary aim of this study was to determine optimal thresholds of preoperative and perioperative changes in high-sensitivity cardiac troponin T (hs-cTnT) to predict MACCE and mortality.
Prospective, observational, cohort study in patients ≥50 yr of age undergoing elective major noncardiac surgery at seven hospitals in Sweden. The exposures were hs-cTnT measured before and days 0–3 after surgery. Two previously published thresholds for myocardial injury and two thresholds identified using receiver operating characteristic analyses were evaluated using multivariable logistic regression models and externally validated. The weighted comparison net benefit method was applied to determine the additional value of hs-cTnT thresholds when compared with the Revised Cardiac Risk Index (RCRI). The primary outcome was a composite of 30-day all-cause mortality and MACCE.
We included 1291 patients between April 2017 and December 2020. The primary outcome occurred in 124 patients (9.6%). Perioperative increase in hs-cTnT ≥14 ng L⁻¹ above preoperative values provided statistically optimal model performance and was associated with the highest risk for the primary outcome (adjusted odds ratio 2.9, 95% confidence interval 1.8–4.7). Validation in an independent, external cohort confirmed these findings. A net benefit over RCRI was demonstrated across a range of clinical thresholds.
Perioperative increases in hsTnT ≥14 ng L⁻¹ above baseline values identifies acute perioperative myocardial injury and provides a net prognostic benefit when added to RCRI for the identification of patients at high risk of death and MACCE.
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Elevated cardiac troponin before surgery: perhaps not so benign
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Fourth Universal Definition of Myocardial Infarction (2018)
2018, Global Heart
Citation Excerpt :
Knowledge about hs-cTn values at baseline can help to identify patients having chronic cTn elevation before surgery, as well as those at increased risk during and after the procedure [79,80]. Measurement of hs-cTn in post-operative samples reveals that as many as 35% of patients have levels above the 99th percentile URL, and 17% have an elevation and a rising pattern of values indicative of evolving myocardial injury [81]. Those with a rising pattern of elevated hs-cTn values are at particular risk; the greater the rise, the greater the risk [82,83].
Fourth Universal Definition of Myocardial Infarction (2018)
2018, Journal of the American College of Cardiology
Comparison of high-sensitivity cardiac troponin I and T for the prediction of cardiac complications after non-cardiac surgery
2018, American Heart Journal
We aimed to directly compare preoperative high-sensitivity cardiac troponin (hs-cTn) I and T concentration for the prediction of major cardiac complications after non-cardiac surgery.
We measured hs-cTnI and hs-cTnT preoperatively in a blinded fashion in 1022 patients undergoing non-cardiac surgery. The primary endpoint was a composite of major cardiac complications including cardiac death, cardiac arrest, myocardial infarction, clinically relevant arrhythmias, and acute heart failure within 30 days. We hypothesized that the type of surgery may impact on the predictive accuracy of hs-cTnI/T and stratified all analyses according to the type of surgery.
Major cardiac complications occurred in 108 (11%) patients, 58/243 (24%) patients undergoing vascular surgery and 50/779 (6%, P < .001) patients undergoing non-vascular surgery. Using regulatory-approved 99th percentile cut-off concentrations, preoperative hs-cTnI elevations were less than one-fifth as common as preoperative hs-cTnT elevations (P < .001). Among patients undergoing vascular surgery, preoperative hs-cTnI concentrations, but not hs-cTnT, was an independent predictor of cardiac complications (adjusted odds ratio (aOR) 1.5, 95% confidence interval (95% CI) 1.0–2.1). The area under the receiver-operating characteristics curve (AUC) was 0.67 (95% CI, 0.59–0.75) for hs-cTnI versus 0.59 (95% CI 0.51–0.67, P = .012) for hs-cTnT. In contrast, among patients undergoing non-vascular surgery both preoperative hs-cTnI and hs-cTnT were independent predictors of the primary endpoint (aOR 1.6, 95% CI 1.3–2.0, and aOR 3.0, 95% CI 2.0–4.6, respectively) and showed higher predictive accuracy (AUC 0.77, 95% CI, 0.71–0.83, and 0.79, 95% CI 0.73–0.85, P = ns).
Preoperative hs-cTnI and hs-cTnT concentrations predict major cardiac complications after non-vascular surgery, while, in patients undergoing vascular surgery, hs-cTnI may have better accuracy.
The Relevance of Implementing the Systematic Screening of Perioperative Myocardial Injury in Noncardiac Surgery Patients
2023, Journal of Clinical Medicine

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^☆: Sources of support: grants from the CANadian Network and Centre for Trials Internationally (CANNeCTIN), Canadian Institutes of Health Research, the Heart and Stroke Foundation of Ontario, Diagnostic Services of Manitoba, and Roche Diagnostics.

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High sensitivity troponin T concentrations in patients undergoing noncardiac surgery: A prospective cohort study☆

Abstract

Objectives

Design and methods

Results

Conclusion

Introduction

Section snippets

Study population

Results

Discussion

Acknowledgments

Clin Biochem

Clin Chim Acta

Major vascular complications in patients undergoing noncardiac surgery: the magnitude of the problem, risk prediction, surveillance, and prevention

Analytical validation of a high-sensitivity cardiac troponin T assay

Clin Chem

High-sensitivity cardiac troponin T for early prediction of evolving non-ST-segment elevation myocardial infarction in patients with suspected acute coronary syndrome and negative troponin results on admission

Clin Chem