Myocardial Injury after Noncardiac Surgery: A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes
Botto, F.; Alonso-Coello, P.; Chan, M.T.V.; Villar, J.C.; Xavier, D.; Srinathan, S.K.; Guyatt, G.; Cruz, P.; Graham, M.; Wang, C.Y.; Berwanger, O.; Pearse, R.M.; Biccard, B.M.; Abraham, V.; Málaga Rodríguez, Germán Javier; Hillis, G.S.; Rodseth, R.N.; Cook, D.; Polanczyk, C.A.; Szczeklik, W.; Sessler, D.I.; Sheth, T.; Ackland, G.L.; Leuwer, M.; Garg, A.X.; Lemanach, Y.; Pettit, S.; Heels-Ansdell, D.; Luratibuse, G.; Walsh, M.; Sapsford, R.; Schünemann, H.J.; Kurz, A.; Thomas, S.; Mrkobrada, M.; Thabane, L.; Gerstein, H.; Paniagua, P.; Nagele, P.; Raina, P.; Yusuf, S.; Devereaux, P.J.; McQueen, M.J.; Bhandari, M.; Bosch, J.; Buckley, N.; Chow, C.K.; Halliwell, R.; Li, S.; Lee, V.W.; Mooney, J.; Furtado, M.V.; Suzumura, E.; Santucci, E.; Leite, K.; Santo, J.A.D.E.; Jardim, C.A.P.; Cavalcanti, A.B.; Guimaraes, H.P.; Jacka, M.J.; McAlister, F.; McMurtry, S.; Townsend, D.; Pannu, N.; Bagshaw, S.; Bessissow, A.; Duceppe, E.; Eikelboom, J.; Ganame, J.; Hankinson, J.; Hill, S.; Jolly, S.; Lamy, A.; Ling, E.; Magloire, P.; Pare, G.; Reddy, D.; Szalay, D.; Tittley, J.; Weitz, J.; Whitlock, R.; Darvish-Kazim, S.; Debeer, J.; Kavsak, P.; Kearon, C.; Mizera, R.; O'Donnell, M.; Pinthus, J.; Ribas, S.; Simunovic, M.; Tandon, V.; Vanhelder, T.; Winemaker, M.; McDonald, S.; O'Bryne, P.; Patel, A.; Paul, J.; Punthakee, Z.; Raymer, K.; Salehian, O.; Spencer, F.; Walter, S.; Worster, A.; Adili, A.; Clase, C.; Crowther, M.; Douketis, J.; Gangji, A.; Jackson, P.; Lim, W.; Lovrics, P.; Mazzadi, S.; Orovan, W.; Rudkowski, J.; Soth, M.; Tiboni, M.; Acedillo, R.; Hildebrand, A.; Lam, N.; MacNeil, D.; Roshanov, P.S.; Ramsey, C.; John, P.S.; Thorlacius, L.; Siddiqui, F.S.; Grocott, H.P.; McKay, A.; Lee, T.W.R.; Amadeo, R.; Funk, D.; McDonald, H.; Zacharias, J.; Cortés, O.L.; Chaparro, M.S.; Vásquez, S.; Castañeda, A.; Ferreira, S.; Coriat, P.; Monneret, D.; Goarin, J.P.; Esteve, C.I.; Royer, C.; Daas, G.; Choi, G.Y.S.; Gin, T.; Lit, L.C.W.; Sigamani, A.; Faruqui, A.; Dhanpal, R.; Almeida, S.; Cherian, J.; Furruqh, S.; Afzal, L.; George, P.; Mala, S.; Muti, P.; Vizza, E.; Wang, C.Y.; Ong, G.S.Y.; Mansor, M.; Tan, A.S.B.; Shariffuddin, I.I.; Vasanthan, V.; Hashim, N.H.M.; Undok, A.W.; Ki, U.; Lai, H.Y.; Ahmad, W.A.; Razack, A.H.A.; Valderrama-Victoria, V.; Loza-Herrera, J.D.; Lazo Porras, María de los Ángeles; Rotta-Rotta, A.; Sokolowska, B.; Musial, J.; Gorka, J.; Iwaszczuk, P.; Kozka, M.; Chwala, M.; Raczek, M.; Mrowiecki, T.; Kaczmarek, B.; Cassimjee, H.; Gopalan, D.; Kisten, T.; Mugabi, A.; Naidoo, P.; Naidoo, R.; Skinner, D.; Torborg, A.; Urrutia, G.; Maestre, M.L.; Santaló, M.; Gonzalez, R.; Font, A.; Martínez, C.; Pelaez, X.; De Antonio, M.; Villamor, J.M.; García, J.A.; Ferré, M.J.; Popova, E.; Garutti, I.; Fernández, C.; Palencia, M.; Díaz, S.; Del Castillo, T.; Varela, A.; De Miguel, A.; Muñoz, M.; Piñeiro, P.; Cusati, G.; Del Barrio, M.; Membrillo, M.J.; Orozco, D.; Reyes, F.; Sapsford, R.J.; Barth, J.; Scott, J.; Hall, A.; Howell, S.; Lobley, M.; Woods, J.; Howard, S.; Fletcher, J.; Dewhirst, N.; Williams, C.; Rushton, A.; Welters, I.; Leuwer, M.; Khan, A.; Niebrzegowska, E.; Benton, S.; Wragg, A.; Archbold, A.; Smith, A.; McAlees, E.; Ramballi, C.; MacDonald, N.; Januszewska, M.; Stephens, R.; Reyes, A.; Paredes, L.G.; Sultan, P.; Cain, D.; Whittle, J.; Del Arroyo, A.G.; Sun, Z.; Finnegan, P.S.; Egan, C.; Honar, H.; Shahinyan, A.; Panjasawatwong, K.; Fu, A.Y.; Wang, S.; Reineks, E.; Blood, J.; Kalin, M.; Gibson, D.; Wildes, T.
Date:
2014
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 Objetives: 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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