Association Between Electrocardiographic Changes and Myocardial Injury or Death After Cardiac Surgery

Emilie P Belley-Côté¹, Richard P Whitlock², André Lamy², Muhammad Mustafa Alhussein³, Vladimir Lomivorotov⁴, Katheryn Brady⁵, Matthew T V Chan⁶, Rene V Allard⁷, Silvia Ajello⁸, Chew Yin Wang⁹, Domenico Paparella¹⁰, Stephen Fremes¹¹, Gerard Urrútia¹², Ludhmila A Hajjar¹³, Graham S Hillis¹⁴, Dmitry Shukevich¹⁵, Nicholas L Mills¹⁶, Vito Margari¹⁷, Joseph D Mills¹⁸, J Stephen Billing¹⁹, Emily Methangkool²⁰, Carisi A Polanczyk²¹, Roberto Sant'Anna²², William F McIntyre²³, Jai Mathur²⁴, Yasser Binbraik²⁵, Narendra Jathappa²⁶, Adrian Baranchuk²⁷, Alexander Romanov²⁸, Roman Zhizhov²⁹, Denis Losik²⁹, Daniele De Viti¹⁷, Xue Lin Chan⁹, Tyng Yan Ng³⁰, Francesco Amendolagine¹⁷, Mario Gaudino³¹, Jessica D Spence³², Harvey White³³, Allan S Jaffe³⁴, Joseph S Alpert³⁵, Rajibul Mian³⁶, Stéphanie Bouvier³⁷, Jessica Vincent⁵, Salim Yusuf²³, P J Devereaux²³

Affiliations

¹ Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; World Health Research Trust, Hamilton, Ontario, Canada. Electronic address: emilie.belley-cote@phri.ca.
² Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; World Health Research Trust, Hamilton, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
³ Department of Cardiology, Kettering General Hospital, University of Northampton, Northampton, UK.
⁴ E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation; Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
⁵ Population Health Research Institute, Hamilton, Ontario, Canada.
⁶ The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China.
⁷ Department of Anesthesia, Queen's University, Kingston, Ontario, Canada.
⁸ Cardiac Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
⁹ University of Malaya, Kuala Lumpur, Malaysia.
¹⁰ Università di Foggia, Dipartimento di Scienze Mediche e Chirurgiche, Foggia, Italy; Ospedale Santa Maria, Division of Cardiac Surgery, GVM Care & Research, Bari, Italy.
¹¹ Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
¹² Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca Sant Pau-CIBERESP, Barcelona, Spain.
¹³ Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
¹⁴ Department of Cardiology Royal Perth Hospital and Medical School, University of Western Australia, Perth, Western Australia, Australia.
¹⁵ Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia.
¹⁶ BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, University of Edinburgh, Edinburgh, UK.
¹⁷ Ospedale Santa Maria, Division of Cardiac Surgery, GVM Care & Research, Bari, Italy.
¹⁸ Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.
¹⁹ Department of Cardiothoracic Surgery, New Cross Hospital, Wolverhampton, UK.
²⁰ Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, California, USA.
²¹ Hospital Moinhos de Vento, Porto Alegre, Brazil; Hospital de Clínicas de Porto Alegre, Brazil.
²² Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, Brazil.
²³ Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; World Health Research Trust, Hamilton, Ontario, Canada.
²⁴ University College London Hospitals NHS Foundation Trust, London, UK.
²⁵ Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
²⁶ Nanjappa Life Care, Karnataka, India.
²⁷ Department of Medicine, Queen's University, Kingston, Ontario, Canada.
²⁸ E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation; Novosibirsk State Medical University, Novosibirsk, Russian Federation.
²⁹ E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation.
³⁰ Pantai Hospital, Kuala Lumpur, Malaysia.
³¹ Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
³² Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; World Health Research Trust, Hamilton, Ontario, Canada; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.
³³ Green Lane Cardiovascular Services, Auckland City Hospital, Te Whatu Ora-Health New Zealand, Te Toka Tumai, Auckland, New Zealand.
³⁴ Cardiovascular Department and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
³⁵ University of Arizona College of Medicine, Tucson, Arizona, USA.
³⁶ Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
³⁷ Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

PMID: 41015246
DOI: 10.1016/j.cjca.2025.09.035

Free article

Association Between Electrocardiographic Changes and Myocardial Injury or Death After Cardiac Surgery

Emilie P Belley-Côté et al. Can J Cardiol. 2025.

Free article

. 2025 Sep 26:S0828-282X(25)01187-0.

doi: 10.1016/j.cjca.2025.09.035. Online ahead of print.

Authors

Affiliations

¹ Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; World Health Research Trust, Hamilton, Ontario, Canada. Electronic address: emilie.belley-cote@phri.ca.
² Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; World Health Research Trust, Hamilton, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
³ Department of Cardiology, Kettering General Hospital, University of Northampton, Northampton, UK.
⁴ E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation; Department of Anesthesiology and Perioperative Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
⁵ Population Health Research Institute, Hamilton, Ontario, Canada.
⁶ The Chinese University of Hong Kong, Hong Kong Special Administrative Region of China.
⁷ Department of Anesthesia, Queen's University, Kingston, Ontario, Canada.
⁸ Cardiac Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
⁹ University of Malaya, Kuala Lumpur, Malaysia.
¹⁰ Università di Foggia, Dipartimento di Scienze Mediche e Chirurgiche, Foggia, Italy; Ospedale Santa Maria, Division of Cardiac Surgery, GVM Care & Research, Bari, Italy.
¹¹ Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
¹² Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Institut de Recerca Sant Pau-CIBERESP, Barcelona, Spain.
¹³ Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
¹⁴ Department of Cardiology Royal Perth Hospital and Medical School, University of Western Australia, Perth, Western Australia, Australia.
¹⁵ Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia.
¹⁶ BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, University of Edinburgh, Edinburgh, UK.
¹⁷ Ospedale Santa Maria, Division of Cardiac Surgery, GVM Care & Research, Bari, Italy.
¹⁸ Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, UK.
¹⁹ Department of Cardiothoracic Surgery, New Cross Hospital, Wolverhampton, UK.
²⁰ Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, California, USA.
²¹ Hospital Moinhos de Vento, Porto Alegre, Brazil; Hospital de Clínicas de Porto Alegre, Brazil.
²² Instituto de Cardiologia do Rio Grande do Sul, Porto Alegre, Brazil.
²³ Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; World Health Research Trust, Hamilton, Ontario, Canada.
²⁴ University College London Hospitals NHS Foundation Trust, London, UK.
²⁵ Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
²⁶ Nanjappa Life Care, Karnataka, India.
²⁷ Department of Medicine, Queen's University, Kingston, Ontario, Canada.
²⁸ E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation; Novosibirsk State Medical University, Novosibirsk, Russian Federation.
²⁹ E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation.
³⁰ Pantai Hospital, Kuala Lumpur, Malaysia.
³¹ Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA.
³² Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; World Health Research Trust, Hamilton, Ontario, Canada; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada.
³³ Green Lane Cardiovascular Services, Auckland City Hospital, Te Whatu Ora-Health New Zealand, Te Toka Tumai, Auckland, New Zealand.
³⁴ Cardiovascular Department and Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
³⁵ University of Arizona College of Medicine, Tucson, Arizona, USA.
³⁶ Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
³⁷ Department of Surgery, McMaster University, Hamilton, Ontario, Canada.

PMID: 41015246
DOI: 10.1016/j.cjca.2025.09.035

Abstract

Background: The relationship between myocardial injury after cardiac surgery (MICS), ischemia on electrocardiogram (ECG), and mortality is uncertain. In this study we aimed to determine whether potential ischemic ECG changes after cardiac surgery are associated with 30-day mortality.

Methods: In a cohort of adults who underwent cardiac surgery, experts interpreted ECGs preoperatively; on postoperative days 0, 1, 2, and 3; and on the last day before discharge (59,539 total ECGs reviewed) for new potential ischemic ECG changes.

Results: Among 12,594 patients, 9097 (72.2%) had potential ischemic ECG changes; 259 (2.1%) died within 30 days after surgery. Among patients with troponin elevation meeting MICS criteria, in models adjusting for EuroSCORE II, the hazard ratio (HR) for 30-day mortality was 0.57 (95% confidence interval [CI] 0.35-0.94, P = 0.03) for new Q waves, 2.17 (95% CI 1.14-4.13, P = 0.02) for ST depression ≥ 2 mm, and 0.58 (95% CI 0.39-0.87, P = 0.007) for T-wave inversion 1-1.9 mm. ST elevation was not significantly associated with 30-day mortality. The only ECG change for which coronary artery bypass grafting (CABG) was an effect modifier was new left bundle branch block (LBBB), with an HR of 2.78 (95% CI 1.69-4.60, P = 0.0001) with CABG and an HR of 1.10 (95% CI 0.54-2.21, P = 0.27) without CABG (P value for interaction = 0.03).

Conclusions: After cardiac surgery, potential ischemic ECG changes are common and have divergent associations with mortality. ST depression was associated with a higher risk of death, whereas new Q waves and T-wave inversions were associated with a lower risk of death. A new LBBB was associated with a higher risk of death only among patients who underwent CABG. Potential ischemic ECG changes are common after cardiac surgery and lack specificity for the diagnosis of myocardial infarction.

Keywords: cardiac surgery; electrocardiogram; myocardial infarction; myocardial injury.

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Association Between Electrocardiographic Changes and Myocardial Injury or Death After Cardiac Surgery

Affiliations

Association Between Electrocardiographic Changes and Myocardial Injury or Death After Cardiac Surgery

Authors

Affiliations

Abstract

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