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Anesthesiology:
doi: 10.1097/ALN.0000000000000113
Perioperative Medicine: Clinical Science

Myocardial Injury after Noncardiac Surgery: A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes

The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Writing Group, on behalf of The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Investigators; Appendix 1. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study Investigators Writing Group; Botto, Fernando M.D.; Alonso-Coello, Pablo M.D.; Chan, Matthew T. V. M.B.B.S.; Villar, Juan Carlos M.D., Ph.D.; Xavier, Denis M.D., M.Sc.; Srinathan, Sadeesh M.D., M.Sc.; Guyatt, Gordon M.D., M.Sc.; Cruz, Patricia M.D.; Graham, Michelle M.D.; Wang, C. Y. M.B.Ch.B.; Berwanger, Otavio M.D.; Pearse, Rupert M. M.B.B.S.; Biccard, Bruce M. M.B.Ch.B., Ph.D.; Abraham, Valsa M.D.; Malaga, German M.D., M.Sc.; Hillis, Graham S. M.B.Ch.B., Ph.D.; Rodseth, Reitze N. M.B.Ch.B., Ph.D.; Cook, Deborah M.D., M.Sc.; Polanczyk, Carisi A. M.D.; Szczeklik, Wojciech M.D., Ph.D.; Sessler, Daniel I. M.D.; Sheth, Tej M.D.; Ackland, Gareth L. M.D., Ph.D.; Leuwer, Martin M.D., Ph.D.; Garg, Amit X. M.D., Ph.D.; LeManach, Yannick M.D., Ph.D.; Pettit, Shirley R.N.; Heels-Ansdell, Diane M.Sc.; LuratiBuse, Giovanna M.D.; Walsh, Michael M.D., M.Sc.; Sapsford, Robert M.B.B.S., M.D.; Schünemann, Holger J. M.D., Ph.D.; Kurz, Andrea M.D.; Thomas, Sabu M.D.; Mrkobrada, Marko M.D.; Thabane, Lehana Ph.D.; Gerstein, Hertzel M.D., M.Sc.; Paniagua, Pilar M.D.; Nagele, Peter M.D., M.Sc.; Raina, Parminder Ph.D.; Yusuf, Salim M.D., D.Phil.; Devereaux, P. J. M.D., Ph.D.; Appendix 2. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN Operations Committee; Devereaux, P. J. M.D., Ph.D.; Sessler, Daniel I. M.D.; Walsh, Michael M.D., M.Sc.; Guyatt, Gordon M.D., M.Sc.; McQueen, Matthew J. M.B.Ch.B., Ph.D.; Bhandari, Mohit M.D., M.Sc.; Cook, Deborah M.D., M.Sc.; Bosch, Jackie M.Sc.; Buckley, Norman M.D., M.Sc.; Yusuf, Salim M.D., D.Phil.; The Vascular events In noncardiac Surgery patIents cOhort evaluatioN VISION Study Investigators; Chow, Clara K. M.B.B.S.; Hillis, Graham S. M.B.B.S.; Halliwell, Richard M.B.B.S.; Li, Stephen M.B.B.S.; Lee, Vincent W. M.B.B.S.; Mooney, John M.B.B.S.; Polanczyk, Carisi A. M.D.; Furtado, Mariana V. M.D.; Berwanger, Otavio M.D.; Suzumura, Erica P.T.; Santucci, Eliana P.T.; Leite, Katia M.Sc.; Santo, Jose Amalth do Espirirto M.D.; Jardim, Cesar A. P. M.D.; Cavalcanti, Alexandre Biasi M.D.; Guimaraes, Helio Penna Ph.D.; Jacka, Michael J. M.D.; Graham, Michelle M.D.; McAlister, Finlay M.D.; McMurtry, Sean M.D.; Townsend, Derek M.D.; Pannu, Neesh M.D.; Bagshaw, Sean M.D.; Bessissow, Amal M.D.; Bhandari, Mohit M.D.; Duceppe, Emmanuelle M.D.; Eikelboom, John M.D.; Ganame, Javier M.D.; Hankinson, James M.D.; Hill, Stephen Ph.D.; Jolly, Sanjit M.D.; Lamy, Andre M.D.; Ling, Elizabeth M.D.; Magloire, Patrick M.D.; Pare, Guillaume M.D.; Reddy, Deven M.D.; Szalay, David M.D.; Tittley, Jacques M.D.; Weitz, Jeff M.D.; Whitlock, Richard M.D.; Darvish-Kazim, Saeed M.D.; DeBeer, Justin M.D.; Kavsak, Peter Ph.D.; Kearon, Clive M.D.; Mizera, Richard M.D.; O’Donnell, Martin M.D.; McQueen, Matthew M.D.; Pinthus, Jehonathan M.D.; Ribas, Sebastian M.D.; Simunovic, Marko M.D.; Tandon, Vikas M.D.; VanHelder, Tomas M.D.; Winemaker, Mitchell M.D.; Gerstein, Hertzel M.D.; McDonald, Sarah M.D.; O’Bryne, Paul M.D.; Patel, Ameen M.D.; Paul, James M.D.; Punthakee, Zubin M.D.; Raymer, Karen M.D.; Salehian, Omid M.D.; Spencer, Fred M.D.; Walter, Stephen Ph.D.; Worster, Andrew M.D.; Adili, Anthony M.D.; Clase, Catherine M.D.; Cook, Deborah M.D.; Crowther, Mark M.D.; Douketis, James M.D.; Gangji, Azim M.D.; Jackson, Paul M.D.; Lim, Wendy M.D.; Lovrics, Peter M.D.; Mazzadi, Sergio M.D.; Orovan, William M.D.; Rudkowski, Jill M.D.; Soth, Mark M.D.; Tiboni, Maria M.D.; Acedillo, Rey M.D.; Garg, Amit M.D.; Hildebrand, Ainslie M.D.; Lam, Ngan M.D.; MacNeil, Danielle M.D.; Mrkobrada, Marko M.D.; Roshanov, Pavel S. M.Sc.; Srinathan, Sadeesh K. M.D.; Ramsey, Clare M.D.; John, Philip St. M.D.; Thorlacius, Laurel Ph.D.; Siddiqui, Faisal S. M.D.; Grocott, Hilary P. M.D.; McKay, Andrew M.D.; Lee, Trevor W. R. M.D.; Amadeo, Ryan M.D.; Funk, Duane M.D.; McDonald, Heather M.D.; Zacharias, James M.D.; Villar, Juan Carlos M.D.; Cortés, Olga Lucía Ph.D.; Chaparro, Maria Stella R.N.; Vásquez, Skarlett R.N.; Castañeda, Alvaro R.N.; Ferreira, Silvia M.D.; Coriat, Pierre M.D.; Monneret, Denis Pharm.D.; Goarin, Jean Pierre M.D.; Esteve, Cristina Ibanez M.D.; Royer, Catherine M.D.; Daas, Georges M.D.; Chan, Matthew T. V. M.B.; Choi, Gordon Y. S. M.B.; Gin, Tony M.D.; Lit, Lydia C. W. Ph.D.; Xavier, Denis M.D.; Sigamani, Alben M.D.; Faruqui, Atiya M.D.; Dhanpal, Radhika M.D.; Almeida, Smitha M.D.; Cherian, Joseph M.S.; Furruqh, Sultana M.D.; Abraham, Valsa M.D.; Afzal, Lalita M.D.; George, Preetha M.B.B.S.; Mala, Shaveta M.B.B.S.; Schünemann, Holger M.D.; Muti, Paola M.D.; Vizza, Enrico M.D.; Wang, C. Y. M.B.Ch.B.; Ong, G. S. Y. M.B.B.S.; Mansor, Marzida M.B.B.S.; Tan, Alvin S. B. M.B.B.S.; Shariffuddin, Ina I. M.B.Ch.B.; Vasanthan, V. M.B.B.S.; Hashim, N. H. M. M.B.B.S.; Undok, A. Wahab M.B.B.S.; Ki, Ushananthini M.B.B.S.; Lai, Hou Yee M.B.B.S.; Ahmad, Wan Azman M.B.B.S.; Razack, Azad H. A. M.B.B.S.; Malaga, German M.D.; Valderrama-Victoria, Vanessa M.D.; Loza-Herrera, Javier D. M.D.; De Los Angeles Lazo, Maria M.D.; Rotta-Rotta, Aida M.D.; Szczeklik, Wojciech M.D.; Sokolowska, Barbara M.D.; Musial, Jacek M.D.; Gorka, Jacek M.D.; Iwaszczuk, Pawel M.D.; Kozka, Mateusz M.D.; Chwala, Maciej M.D.; Raczek, Marcin M.D.; Mrowiecki, Tomasz M.D.; Kaczmarek, Bogusz M.D.; Biccard, Bruce M.B.Ch.B.; Cassimjee, Hussein M.B.Ch.B.; Gopalan, Dean M.B.Ch.B.; Kisten, Theroshnie M.B.Ch.B.; Mugabi, Aine M.B.Ch.B.; Naidoo, Prebashini M.B.B.Ch.; Naidoo, Rubeshan M.B.Ch.B.; Rodseth, Reitze M.B.Ch.B.; Skinner, David M.B.Ch.B.; Torborg, Alex M.B.Ch.B.; Paniagua, Pilar M.D.; Urrutia, Gerard M.D.; Maestre, Mari Luz M.D.; Santaló, Miquel M.D.; Gonzalez, Raúl M.D.; Font, Adrià M.D.; Martínez, Cecilia M.D.; Pelaez, Xavier M.D.; De Antonio, Marta M.D.; Villamor, Jose Marcial M.D.; García, Jesús Álvarez M.D.; Ferré, Maria José M.D.; Popova, Ekaterina M.D.; Alonso-Coello, Pablo M.D.; Garutti, Ignacio M.D.; Cruz, Patricia M.D.; Fernández, Carmen M.D.; Palencia, Maria M.D.; Díaz, Susana M.D.; del Castillo, Teresa M.D.; Varela, Alberto M.D.; de Miguel, Angeles M.D.; Muñoz, Manuel M.D.; Piñeiro, Patricia M.D.; Cusati, Gabriel M.D.; del Barrio, Maria M.D.; Membrillo, Maria José M.D.; Orozco, David M.D.; Reyes, Fidel M.D.; Sapsford, Robert J. M.B.B.S.; Barth, Julian M.B.B.S.; Scott, Julian M.B.B.S.; Hall, Alistair M.B.B.S.; Howell, Simon M.B.B.S.; Lobley, Michaela R.G.N.; Woods, Janet R.G.N.; Howard, Susannah R.G.N.; Fletcher, Joanne R.G.N.; Dewhirst, Nikki R.G.N.; Williams, C. M.D.; Rushton, A. M.D.; Welters, I. M.D.; Leuwer, M. M.D.; Pearse, Rupert M.D.; Ackland, Gareth M.D.; Khan, Ahsun M.D.; Niebrzegowska, Edyta M.Sc.; Benton, Sally F.R.C.Path.; Wragg, Andrew Ph.D.; Archbold, Andrew M.D.; Smith, Amanda R.G.N.; McAlees, Eleanor B.Sc.; Ramballi, Cheryl F.I.B.M.S.; MacDonald, Neil F.R.C.A.; Januszewska, Marta M.Sc.; Stephens, Robert F.R.C.A.; Reyes, Anna B.Sc.; Paredes, Laura Gallego B.Sc.; Sultan, Pervez F.R.C.A.; Cain, David F.R.C.A.; Whittle, John F.R.C.A.; del Arroyo, Ana Gutierrez F.R.C.A.; Sessler, Daniel I. M.D.; Kurz, Andrea M.D.; Sun, Zhuo M.D.; Finnegan, Patrick S. B.Sc.; Egan, Cameron B.Sc.; Honar, Hooman M.D.; Shahinyan, Aram M.D.; Panjasawatwong, Krit M.D.; Fu, Alexander Y. M.D.; Wang, Sihe Ph.D.; Reineks, Edmunds M.D.; Nagele, Peter M.D.; Blood, Jane R.N.; Kalin, Megan B.Sc.; Gibson, David B.Sc.; Wildes, Troy M.D.

Supplemental Author Material
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Abstract

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS.
Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria.
Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom.
Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

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