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High-Sensitivity Cardiac Troponin T Improves the Diagnosis of Perioperative MI

Brown, Jamie C. MD*; Samaha, Eslam MD*; Rao, Srikar MD*; Helwani, Mohammad A. MD, MSPH*; Duma, Andreas MD, MSc*; Brown, Frank BSc*; Gage, Brian F. MD, MSc; Miller, J. Philip AB†‡; Jaffe, Allan S. MD§; Apple, Fred S. PhD; Scott, Mitchell G. PhD; Nagele, Peter MD, MSc*

doi: 10.1213/ANE.0000000000002240
Cardiovascular Anesthesiology: Original Clinical Research Report

BACKGROUND: The diagnosis of myocardial infarction (MI) after noncardiac surgery has traditionally relied on using relatively insensitive contemporary cardiac troponin (cTn) assays. We hypothesized that using a recently introduced novel high-sensitivity cTnT (hscTnT) assay would increase the detection rate of perioperative MI.

METHODS: In this ancillary study of the Vitamins in Nitrous Oxide trial, readjudicated incidence rates of myocardial injury (new isolated cTn elevation) and MI were compared when diagnosed by contemporary cTnI versus hscTnT. We probed various relative (eg, >50%) or absolute (eg, +5 ng/L) hscTnT change metrics. Inclusion criteria for this ancillary study were the presence of a baseline and at least 1 postoperative hscTnT value.

RESULTS: Among 605 patients, 70 patients (12%) had electrocardiogram changes consistent with myocardial ischemia; 82 patients (14%) had myocardial injury diagnosed by contemporary cTnI, 31 (5.1%) of which had an adjudicated MI. After readjudication, 67 patients (11%) were diagnosed with MI when using hscTnT, a 2-fold increase. Incidence rates of postoperative myocardial injury ranged from 12% (n = 73) to 65% (n = 393) depending on the hscTnT metric used. Incidence rates of MI using various hscTnT change metrics and the presence of ischemic electrocardiogram changes, but without event adjudication, ranged from 3.6% (n = 22) to 12% (n = 74), a >3-fold difference. New postoperative hscTnT elevation, either by absolute or relative hscTnT change metric, was associated with an up to 5-fold increase in 6-month mortality.

CONCLUSIONS: The use of hscTnT compared to contemporary cTnI increases the detection rate of perioperative MI by a factor of 2. Using different absolute or relative hscTnT change metrics may lead to under- or overdiagnosis of perioperative MI.

Published ahead of print July 14, 2017.

From the *Division of Clinical and Translational Research, Department of Anesthesiology, Department of Internal Medicine, and Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri; §Cardiovascular Division, Department of Internal Medicine and Division of Core Clinical Laboratory Services, Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota; Department of Laboratory Medicine & Pathology, Hennepin County Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota; and Department of Pathology & Immunology, Washington University School of Medicine, St Louis, Missouri.

Accepted for publication April 21, 2017.

Published ahead of print July 14, 2017.

Funding: The parent Vitamins in Nitrous Oxide trial was funded by a grant from the National Institute for General Medical Sciences (K23 GM087534) and a grant to Washington University Institute of Clinical and Translational Sciences (UL1RR024992), the Foundation for Anesthesia Education and Research (FAER), and the Division of Clinical and Translational Research, Department of Anesthesiology, Washington University. Roche Diagnostics (Indianapolis, IN) provided the hscTnT assays and covered the costs of running these assays. P. N. is currently funded by NIH/NHLBI (R01HL126892). P. N. was supported by Roche Diagnostics US and Abbott Diagnostics. M. G. S. was supported by Siemens Healthcare Diagnostic, Abbott Diagnostics, and Instrumentation Laboratories. F. S. A. was supported by Minneapolis Medical Research Foundation, but received no salary support for work related to cardiac troponin: Abbott Diagnostics, Siemens, Ortho-Clinical Diagnostics, Roche Diagnostics, Radiometer.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Peter Nagele, MD, MSc, Department of Anesthesiology, Washington University School of Medicine, 660 S Euclid Ave, Box 8054, St Louis, MO 63110. Address e-mail to nagelep@wustl.edu.

© 2017 International Anesthesia Research Society
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