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Observational Study
. 2017 Jun 6;6(6):e005672.
doi: 10.1161/JAHA.117.005672.

Associations Between Cardiac Troponin, Mechanism of Myocardial Injury, and Long-Term Mortality After Noncardiac Vascular Surgery

Grant W Reed  1 , Samuel Horr  2 , Laura Young  2 , Joshua Clevenger  2 , Umair Malik  2 , Stephen G Ellis  2 , A Michael Lincoff  2 , Steven E Nissen  2 , Venu Menon  2
Affiliations
Observational Study

Associations Between Cardiac Troponin, Mechanism of Myocardial Injury, and Long-Term Mortality After Noncardiac Vascular Surgery

Grant W Reed et al. J Am Heart Assoc. .

Abstract

Background: The time-sensitive hazard of perioperative cardiac troponin T (cTnT) elevation and whether long-term mortality differs by mechanism of myocardial injury are poorly understood.

Methods and results: In this observational study of 12 882 patients who underwent noncardiac vascular surgery, patients were assessed for cTnT sampling within 96 hours postoperatively. Mortality out to 5-years was stratified by cTnT level and mechanism of myocardial injury. During a median follow-up of 26.9 months, there were 2149 (16.7%) deaths. By multivariable Cox proportional hazards analysis, there was a graded increase in mortality with any detectable cTnT compared to <0.01 ng/mL; cTnT 0.01 to 0.029 ng/mL hazard ratio (HR) 1.54 (95% CI 1.18-2.00, P=0.002), 0.03 to 0.099 ng/mL HR 1.86 (95% CI 1.49-2.31, P<0.001), 0.10 to 0.399 ng/mL HR 1.83 (95% CI 1.46-2.31, P<0.001), ≥0.40 ng/mL HR 2.62 (95% CI 2.06-3.32, P<0.001). Mortality for each mechanism of injury was greater than for patients with normal cTnT; baseline cTnT elevation HR 1.71 (95% CI 1.31-2.24; P<0.001), Type 2 myocardial infarction HR 1.88 (95% CI 1.57-2.24; P<0.001), Type 1 MI HR 2.56 (95% CI 2.56, 1.82-3.60; P<0.001). On Kaplan-Meier analysis, long-term survival did not differ between mechanisms. The hazard of mortality was greatest within the first 10 months postsurgery. Consistent results were obtained in confirmatory propensity-score matched analyses.

Conclusions: Any detectable cTnT ≥0.01 ng/mL is associated with increased long-term mortality after vascular surgery. This risk is greatest within the first 10 months postoperatively. While short-term mortality is greatest with Type 1 myocardial infarction, long-term mortality appears independent of the mechanism of injury.

Keywords: mortality; myocardial infarction; postoperative; surgery; troponin T; type 2 MI; type I MI.

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Figures

Figure 1
Figure 1
Frequency of types of vascular surgery in the study population. Most patients had a major aortic or peripheral vascular procedure (63% of total); endovascular peripheral procedures, amputation, AV, fistula, and other minor vascular surgeries were less common. See Table S1 for a comprehensive list of the various surgeries in each of the larger categories summarized above. AAA indicates abdominal aortic aneurysm; AV, arteriovenous.
Figure 2
Figure 2
Kaplan–Meier survival curves for long‐term mortality stratified by cTnT level. Long‐term mortality was similar in patients not sampled and those not detectable (<0.01 ng/mL), whereas there was a graded decline in the probability of survival with any detectable cTnT level, even below the threshold for cTnT elevation (0.03 ng/mL). Log‐rank P<0.001 for the entire model. Values are reported as ng/mL. cTnT indicates cardiac troponin T.
Figure 3
Figure 3
Plot of hazard rate over time stratified by cTnT level. There was a graded increase in the instantaneous hazard of mortality with increasing cTnT level. This risk was apparent immediately postoperatively, greatest within the first 10 months after surgery, but persisted during long‐term follow‐up for all levels of cTnT. cTnT indicates cardiac troponin T.
Figure 4
Figure 4
Kaplan–Meier survival curves for long‐term mortality stratified by mechanism of myocardial injury. Long‐term survival was decreased in all patients with myocardial injury, regardless of myocardial injury. Survival was similar for patients with baseline elevation, Type 2 MI or Type 1 MI. Log‐rank P<0.001 for the entire model. MI indicates myocardial infarction.
Figure 5
Figure 5
Plot of hazard rate over time stratified by mechanism of myocardial injury. Patients with Type 1 MI had the highest hazard of mortality in the short term after noncardiac surgery. However, patients with Type 2 MI and baseline cTnT elevation still had a higher risk than patients with a normal cTnT, and the risk was similar to that of patients with Type 1 MI after ≈10 months. cTnT indicates cardiac troponin T; MI, myocardial infarction.
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