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Randomized Controlled Trial
. 2017 Nov;125(5):1455-1462.
doi: 10.1213/ANE.0000000000002240.

High-Sensitivity Cardiac Troponin T Improves the Diagnosis of Perioperative MI

Jamie C Brown  1 , Eslam Samaha, Srikar Rao, Mohammad A Helwani, Andreas Duma, Frank Brown, Brian F Gage, J Philip Miller, Allan S Jaffe, Fred S Apple, Mitchell G Scott, Peter Nagele
Affiliations
Randomized Controlled Trial

High-Sensitivity Cardiac Troponin T Improves the Diagnosis of Perioperative MI

Jamie C Brown et al. Anesth Analg. 2017 Nov.

Abstract

Background: The diagnosis of myocardial infarction (MI) after noncardiac surgery has traditionally relied on using relatively insensitive contemporary cardiac troponin (cTn) assays. We hypothesized that using a recently introduced novel high-sensitivity cTnT (hscTnT) assay would increase the detection rate of perioperative MI.

Methods: In this ancillary study of the Vitamins in Nitrous Oxide trial, readjudicated incidence rates of myocardial injury (new isolated cTn elevation) and MI were compared when diagnosed by contemporary cTnI versus hscTnT. We probed various relative (eg, >50%) or absolute (eg, +5 ng/L) hscTnT change metrics. Inclusion criteria for this ancillary study were the presence of a baseline and at least 1 postoperative hscTnT value.

Results: Among 605 patients, 70 patients (12%) had electrocardiogram changes consistent with myocardial ischemia; 82 patients (14%) had myocardial injury diagnosed by contemporary cTnI, 31 (5.1%) of which had an adjudicated MI. After readjudication, 67 patients (11%) were diagnosed with MI when using hscTnT, a 2-fold increase. Incidence rates of postoperative myocardial injury ranged from 12% (n = 73) to 65% (n = 393) depending on the hscTnT metric used. Incidence rates of MI using various hscTnT change metrics and the presence of ischemic electrocardiogram changes, but without event adjudication, ranged from 3.6% (n = 22) to 12% (n = 74), a >3-fold difference. New postoperative hscTnT elevation, either by absolute or relative hscTnT change metric, was associated with an up to 5-fold increase in 6-month mortality.

Conclusions: The use of hscTnT compared to contemporary cTnI increases the detection rate of perioperative MI by a factor of 2. Using different absolute or relative hscTnT change metrics may lead to under- or overdiagnosis of perioperative MI.

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Conflict of interest statement

Disclosures:

Brown, Samaha, Rao, Helwani, Duma, Brown, Gage, Miller: No conflicts of interest.

Nagele: Research Support: Roche Diagnostics US; Abbott Diagnostics.

Scott: Research Support - Siemens Healthcare Diagnostic; Abbott Diagnostics, Instrumentation Laboratories; Consulting - Instrumentation Laboratories; Becton-Dickinson, Alere; Speaker fees: Abbott

Jaffe: Consultation: Beckman, Ortho, Abbott, Alere, Critical Diagnostics, Roche, Radiometer, Amgen and theHeart.org

Apple: Industry Grant/Research Support through Minneapolis Medical Research Foundation, no salary, that involve cardiac troponin: Abbott Diagnostics, Siemens, Ortho-Clinical Diagnostics, Roche Diagnostics, Radiometer; Paid Consultant: Instrumentation Laboratories, Alere, T2 Biosystems

Figures

Figure 1.
Figure 1.. Comparison of MI Call Rates between cTnI and hscTnT
Venn diagrams depicting individual comparisons of MI call rates between adjudicated hscTnT MIs (blue), cTnI (bisque), and one of 11 unadjudicated hscTnT absolute or relative change metric (green). Overlapping areas indicate MI cases that were correctly called by both methods; to the right are cases that were falsely classified as MI (false positives) by unadjudicated hscTnT metric; to the left are events that were missed by the unadjudicated hscTnT metric (false negatives), indicated by the red arrows.
Figure 2A-C.
Figure 2A-C.. Unadjusted Kaplan-Meier Survival Curves for MI diagnosed by three representative hscTnT metrics.
All MIs needed evidence if ischemic ECG changes plus either one postoperative hscTnT value >99th% (Fig. 2A), a >50% hscTnT increase (Fig. 2B), or a >5ng/L hscTnT increase (Fig. 2C).
Figure 2A-C.
Figure 2A-C.. Unadjusted Kaplan-Meier Survival Curves for MI diagnosed by three representative hscTnT metrics.
All MIs needed evidence if ischemic ECG changes plus either one postoperative hscTnT value >99th% (Fig. 2A), a >50% hscTnT increase (Fig. 2B), or a >5ng/L hscTnT increase (Fig. 2C).
Figure 2A-C.
Figure 2A-C.. Unadjusted Kaplan-Meier Survival Curves for MI diagnosed by three representative hscTnT metrics.
All MIs needed evidence if ischemic ECG changes plus either one postoperative hscTnT value >99th% (Fig. 2A), a >50% hscTnT increase (Fig. 2B), or a >5ng/L hscTnT increase (Fig. 2C).
Figure 2A-C.
Figure 2A-C.. Unadjusted Kaplan-Meier Survival Curves for MI diagnosed by three representative hscTnT metrics.
All MIs needed evidence if ischemic ECG changes plus either one postoperative hscTnT value >99th% (Fig. 2A), a >50% hscTnT increase (Fig. 2B), or a >5ng/L hscTnT increase (Fig. 2C).
See this image and copyright information in PMC

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