Original Research

Postoperative High-Sensitivity Troponin Monitoring Following Noncardiac Surgery: Evaluating the Effect on Mortality of Associated Perioperative Clinical Events

Matthew W.P. Jackson , Mark Hammonds , Nicola Cunningham , David Austin , Neil Swanson , Mark A. de Belder , Michael J. Stewart
Cardiology Department, The James Cook University Hospital, Middlesbrough, UK
J Anesth Perioper Med 2018; 5(6): 281- 292 . Published on Nov 28, 2018 . doi:10.24015/JAPM.2018.0116
Author & Article info


Background: The 30-day mortality following non-cardiac surgery ranges from 2%-6%. Observational studies have suggested myocardial injury following non-cardiac surgery (MINS) and subsequent vascular events are partly responsible.
Methods: Postoperative high-sensitivity troponin I levels were recorded on in-patients undergoing non-cardiac surgery. Positive results (> 17 ng/L) were categorized by the associated pathophysiological process; “secondary” if associated with sepsis, significant perioperative bleeding or prolonged pathological atrial or ventricular tachyarrhythmias and “primary” if not. The 30-day and 6-month mortality data were collected. Multivariate Cox proportional hazard modeling determined independent predictors of 6-month mortality.
Results: Of 387 patients analyzed, 125 (32%) were over 75 years of age; 192 (50%) were male. The 30-day mortality (2.8%) was comparable to the VISION study (1.9%); 30-day mortality following an elevated postoperative troponin was 5.6%, all associated with sepsis. The 6-month mortality overall was 10%; 21% following any postoperative troponin elevation, 8.6% following “primary” events, 36% and 21% following “secondary” events associated with sepsis and bleeding respectively and 3.7% with normal post-operative troponin. 5% of deaths had vascular causes identified; none had an elevated postoperative troponin. Emergency presentation, sepsis, and abnormal renal function independently predicted 6-month mortality with the emergency presentation being the strongest predictor.  Troponin levels > 1000 ng/l (highly suggestive of independently predicting 6-month mortality (P = 0.06)) occurred in 13 patients (3.4% of the entire cohort); the majority of these patients were emergency admissions requiring high-dependency or intensive care unit admission and 9 had evidence of perioperative sepsis. “Primary” elevated post-operative troponins were not independent predictors of mortality. 
Conclusion: Postoperative high-sensitivity troponin elevation in patients undergoing non-cardiac surgery is associated with 30-day and 6-month mortality. However, early mortality in patients with elevated troponin was largely accounted for by other non-cardiac adverse events; we suggest a mixture of pathophysiological processes are at work rather than solely indicating new vascular events. (Funded by the Regional Innovation Fund of NHS England and the South Tees NHS Foundation Trust Research and Development Fund.) 
Citation: Matthew W.P. Jackson, Mark Hammonds, Nicola Cunningham, David Austin, Neil Swanson, Mark A. de Belder, Michael J. Stewart. Postoperative High-Sensitivity Troponin Monitoring Following Noncardiac Surgery: Evaluating the Effect on Mortality of Associated Perioperative Clinical Events. J Anesth Perioper Med 2018;5:281-292. doi: 10.24015/JAPM.2018.0116
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