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Myocardial Injury After Noncardiac Surgery (MINS) in Vascular Surgical Patients: A Prospective Observational Cohort Study

Biccard, Bruce M., MBChB, FCA, FFARCSI, MMedSci, PhD*; Scott, David Julian Ashbridge, MD(Res); Chan, Matthew T. V., PhD; Archbold, Andrew, MD§; Wang, Chew-Yin, FRCA; Sigamani, Alben, MD||; Urrútia, Gerard, PhD**; Cruz, Patricia, PhD††; Srinathan, Sadeesh K., MD‡‡; Szalay, David, MD§§; Harlock, John, MD¶¶; Tittley, Jacques G., MD, RVT, FRCSC||||; Rapanos, Theodore, BSc, MSc, MD, FRCSC§§; Elias, Fadi, MD§§; Jacka, Michael J., MD***; Malaga, German, MSc†††; Abraham, Valsa, MD‡‡‡; Berwanger, Otavio, MD, PhD§§§; Montes, Félix R., MD¶¶¶; Heels-Ansdell, Diane M., MSc||||||; Hutcherson, Matthew T., BS****; Chow, Clara K., PhD††††; Polanczyk, Carisi A., MD, ScD‡‡‡‡; Szczeklik, Wojciech, PhD§§§§; Ackland, Gareth L., PhD¶¶¶¶; Dubois, Luc, MD, MSc||||||||; Sapsford, Robert J., MD*****; Williams, Colin, MbChB†††††; Cortés, Olga L., PhD‡‡‡‡‡; Le Mananch, Yannick, PhD§§§§§; Devereaux, P. J., PhD¶¶¶¶¶

doi: 10.1097/SLA.0000000000002290

Objective: To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients.

Background: MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described.

Methods: This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring.

Results: The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%–22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%–20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%–3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46–25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1–29.1) and without an ischemic feature (12.2%; 95% CI, 5.3–25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6–82.4).

Conclusions: Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.

*Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa

Leeds teaching Hospitals NHS Trust and University of Leeds, Leeds, United Kingdom

Chinese University of Hong Kong, Shatin, Hong Kong

§Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom

Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia

||Narayana Hrudayalaya Limited, Bengaluru, Karnataka, India

**Institut d’Investigació Biomèdica, Sant Pau (IIB Sant Pau) - CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain

††Anesthesia and Reanimation Service, Hospital Gregorio Marañón, Madrid, Spain

‡‡Department of Surgery, Health Sciences Centre and The University of Manitoba, Manitoba, Canada

§§McMaster University, Hamilton, Ontario, Canada

¶¶Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada

||||Bearish Family Chair in Vascular Surgery, McMaster University, Hamilton, Ontario, Canada

***University of Alberta, Edmonton, Alberta, Canada

†††CONEVID - Universidad peruana Cayetano, Heredia, Peru

‡‡‡Christian Medical College, Ludhiana, Punjab, India

§§§Research Institute HCor - Heart Hospital (Hospital Coração), São Paulo-SP, Brazil

¶¶¶Department of Anesthesiology, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia

||||||Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

****Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH

††††Westmead Hospital and The George Institute of Global Health, University of Sydney, Sydney, Australia

‡‡‡‡Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil

§§§§Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland

¶¶¶¶William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom

||||||||Division of Vascular Surgery, Western University, London, Ontario, Canada

*****Leeds Teaching Hospitals NHDS Trust, Leeds, United Kingdom

†††††Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, United Kingdom

‡‡‡‡‡Research Department, Fundación Cardioinfantil Instituto de Cardiología, Bogotá, Colombia

§§§§§Departments of Anesthesia and Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, Michael DeGroote School of Medicine, McMaster University and Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Ontario, Canada

¶¶¶¶¶Population Health Research Institute, Hamilton, Ontario, Canada.

Reprints: Bruce M. Biccard, MBChB, FCA, FFARCSI, MMedSci, PhD, Department of Anaesthesia and Perioperative Medicine, D23, Groote Schuur Hospital, Main Rd, Observatory, Cape Town 7925, South Africa. E-mail:

Disclosures: The VISION Study funding sources had no role in the design and conduct of the study; in collection, management, analysis, and interpretation of the data; or in preparation or approval of the manuscript.

Sources of support: M.T.V.C., General Research Fund (461412), Research Grant Council, Hong Kong Special Administrative Region; Project Grant (13/008), Australian and New Zealand College of Anesthesiologists. C.K.C., National Health and Medical Research Council and The Heart Foundation of Australia. M.T.H., Canadian Institutes of Health Sciences and Covidien (now Medtronic). C.-Y.W., RG302–14AFR (UMRG)-AFR (Frontier Science), University of Malaya. O.B., Programa PROADi-SUS- Ministry of Health Brazil. R.J.S., National Institute for Health Research (GB) funded. C.W., CLRN. Roche Diagnostics provided the plasma Troponin T assays and some financial support for the VISION Study.

The authors declare no conflict of interests.

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