Prognostic performance of preoperative cardiac troponin and perioperative changes in cardiac troponin for the prediction of major adverse cardiac events and mortality in noncardiac surgery: A systematic review and meta-analysis

Abstract

Background: Increased postoperative cardiac troponin (cTn) independently predicts short-term mortality. Previous studies suggest that preoperative cTn also predicts major adverse cardiovascular events (MACE) and mortality after noncardiac surgery. The value of preoperative and perioperative changes in cTn as a prognostic tool for adverse outcomes has been sparsely investigated.

Methods and findings: A systematic review and meta-analysis of the prognostic value of cTns for adverse outcome was conducted. Adverse outcome was defined as short-term (in-hospital or <30 days) and long-term (>30 days) MACE and/or all-cause mortality, in adult patients undergoing noncardiac surgery. The study protocol (CRD42018094773) was registered with an international prospective register of systematic reviews (PROSPERO). Preoperative cTn was a predictor of short- (OR 4.3, 95% CI 2.9-6.5, p<0.001, adjusted OR 5.87, 95% CI 3.24-10.65, p<0.001) and long-term adverse outcome (OR 4.2, 95% CI 1.0-17.3, p = 0.05, adjusted HR 2.0, 95% CI 1.4-3.0, p<0.001). Perioperative change in cTn was a predictor of short-term adverse outcome (OR 10.1, 95% CI 3.2-32.3, p<0.001). It was not possible to conduct pooled analyses for adjusted estimates of perioperative change in cTn as predictor of short- (a single study identified) and long-term (no studies identified) adverse outcome. Further, it was not possible to conduct pooled analyses for unadjusted estimates of perioperative change in cTn as predictor of long-term adverse outcome, since only one study was identified. Bivariate analysis of sensitivities and specificities were performed, and overall prognostic performance was summarized using summary receiver operating characteristic (SROC) curves. The pooled sensitivity and specificity for preoperative cTn and short-term adverse outcome was 0.43 and 0.86 respectively (area under the SROC curve of 0.68). There were insufficient studies to construct SROCs for perioperative changes in cTn and for long-term adverse outcome.

Conclusion: Our study indicates that although preoperative cTn and perioperative change in cTn might be valuable predictors of MACE and/or all-cause mortality in adult noncardiac surgical patients, its overall prognostic performance remains uncertain. Future large, representative, high-quality studies are needed to establish the potential role of cTns in perioperative cardiac risk stratification.

Fig 1. Flow diagram of study identification and selection.

Fig 2. Unadjusted odds ratios for elevation in preoperative cTn to predict short-term adverse outcome.

Forest plot showing the individual and pooled unadjusted odds ratios from the included studies. cTn = Cardiac troponin. CI = Confidence interval. # = Number of.

Fig 3. Adjusted odds ratios for elevation in preoperative cTn to predict short-term adverse outcome.

Forest plot showing the individual and pooled adjusted odds ratios from the included studies. cTn = Cardiac troponin. CI = Confidence interval. # = Number of.

Fig 4. Unadjusted odds ratios for elevation in preoperative cTn to predict long-term adverse outcome.

Forest plot showing the individual and pooled unadjusted odds ratios from the included studies. cTn = Cardiac troponin. CI = Confidence interval. # = Number of.

Fig 5. Adjusted hazard ratios for elevation in preoperative cTn to predict long-term adverse outcome.

Forest plot showing the individual and pooled adjusted hazard ratios from the included studies. cTn = Cardiac troponin. CI = Confidence interval. # = Number of.

Fig 6. Unadjusted odds ratios for an absolute perioperative change in cTn to predict short-term adverse outcome.

Forest plot showing the individual and pooled unadjusted odds ratios from the included studies. cTn = Cardiac troponin. CI = Confidence interval. # = Number of.

Fig 7. Summary receiver operating characteristic (SROC) curve for prognostic performance of preoperative cTn to predict short-term adverse outcome.

Filled dots = observed data. Unfilled dot = pooled sensitivity (0.43 [CI 0.29–0.58]) and specificity (0.85 [CI 0.73–0.94]). Black curve = SROC curve (AUC = 0.68). Black-lined region = 95% confidence region. Dashed-lined region = 95% prediction region.