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One-Year Mortality, Causes of Death, and Cardiac Interventions in Patients with Postoperative Myocardial Injury

van Waes, Judith A. R. MD; Grobben, Remco B. MD; Nathoe, Hendrik M. MD, PhD; Kemperman, Hans PhD; de Borst, Gert Jan MD, PhD; Peelen, Linda M. PhD; van Klei, Wilton A. MD, PhD; the Cardiac Health After Surgery (CHASE) Investigators; Buhre, Wolfgang F. Professor of Anesthesiology; de Graaff, Jurgen C. Anesthesiologist; Kalkman, Cor J. Professor of Anesthesiology; van Wolfswinkel, Leo Anesthesiologist; Doevendans, Pieter A. Professor of Cardiology; Grobbee, Diederik E. Professor of Epidemiology; van Solinge, Wouter W. Professor of Clinical Chemistry; Leiner, Tim Radiologist; Leenen, Loek P. H. Professor of Trauma Surgery; Moll, Frans L. Professor of Vascular Surgery

doi: 10.1213/ANE.0000000000001313
Cardiovascular Anesthesiology: Research Report
Continuing Medical Education

BACKGROUND: To evaluate the role of routine troponin surveillance in patients undergoing major noncardiac surgery, unblinded screening with cardiac consultation per protocol was implemented at a tertiary care center. In this study, we evaluated 1-year mortality, causes of death, and consequences of cardiac consultation of this protocol.

METHODS: This observational cohort included 3224 patients ≥60 years old undergoing major noncardiac surgery. Troponin I was measured routinely on the first 3 postoperative days. Myocardial injury was defined as troponin I >0.06 μg/L. Regression analysis was used to determine the association between myocardial injury and 1-year mortality. The causes of death, the diagnoses of the cardiologists, and interventions were determined for different levels of troponin elevation.

RESULTS: Postoperative myocardial injury was detected in 715 patients (22%) and was associated with 1-year all-cause mortality (relative risk [RR] 1.4, P = 0.004; RR 1.6, P < 0.001; and RR 2.2, P < 0.001 for minor, moderate, and major troponin elevation, respectively). Cardiac death within 1 year occurred in 3%, 5%, and 11% of patients, respectively, in comparison with 3% of the patients without myocardial injury (P = 0.059). A cardiac consultation was obtained in 290 of the 715 patients (41%). In 119 (41%) of these patients, the myocardial injury was considered to be attributable to a predisposing cardiac condition, and in 111 patients (38%), an intervention was initiated.

CONCLUSIONS: Postoperative myocardial injury was associated with an increased risk of 1-year all-cause but not cardiac mortality. A cardiac consultation with intervention was performed in less than half of these patients. The small number of interventions may be explained by a low suspicion of a cardiac etiology in most patients and lack of consensus for standardized treatment in these patients.

Published ahead of print April 22, 2016

From the *Department of Anesthesiology; Department of Cardiology; Department of Clinical Chemistry and Haematology; §Department of Surgery; and Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.

Department of Anesthesiology

Department of Anesthesiology

Department of Anesthesiology

Department of Anesthesiology

Department of Cardiology

Department of Epidemiology, Julius Center for Health Sciences and Primary Care

Department of Clinical Chemistry and Haematology

Department of Radiology

Division of Surgical Specialties

Division of Surgical Specialties

Accepted for publication February 22, 2016.

Published ahead of print April 22, 2016

Funding: This study was funded by a grant from the International Anesthesia Research Society (Clinical Scholar Research Award 2011 to Dr. Van Klei), by a grant from the Friends of the University Medical Center Utrecht foundation/the Dirkzwager-Assink Fund to Dr. Van Klei, and by departmental sources.

The authors declare no conflicts of interest.

The first two authors contributed equally to this article.

This report was previously presented, in part, at the Annual Meeting of the American Society of Anesthesiologists, October 11, 2014, New Orleans, LA.

Reprints will not be available from the authors.

Address correspondence to Judith A. R. van Waes, MD, University Medical Center Utrecht, Local Mail Q04.2.313, P. O. Box 58800, 3508 GA Utrecht, The Netherlands. Address e-mail to j.a.r.vanwaes@umcutrecht.nl.

© 2016 International Anesthesia Research Society