Troponin Elevations in the Peri-operative Patient€¦ · Troponin Elevations in the Peri-operative Patient Associate Professor Ronald Dick . Case for Discussion 74 yo retired Anaesthetist

Troponin Elevations in the Peri-operative Patient

Associate Professor Ronald Dick

Case for Discussion

74 yo retired Anaesthetist

Elective Total Hip Replacement

Past History of Mild Hypertension

Uneventful operation until transient mild post op hypotension

Med Fellow called

ECG no Change, U + E Normal

Troponin 28 ng/ml (15 upper limit)

A Case of Hypertroponaemia Where to now??

Clinical Options

Ignore it

Repeat it in 6 hours

Transfer to monitored bed

Urgent Cardiology referral for Coronary

angiography

Discussion

What is Troponin?

What causes it to be elevated?

Does a perioperative elevation lead to adverse outcomes?

The way forward from here

Cardiac Ischaemia Biomarkers

Creatinine Kinase (CK)

Creatinine Kinase MB (CKMB)

Troponin TnT, TnI, Tnc

Hs cTnt (high affinity antibodies)

Troponin

Troponin

Troponin Elevations

Elevations suggest myocardial injury

1.Primary Ischaemic Injury

Thrombotic Arterial Occlusion (STEMI, NSTEMI)

2. Secondary Ischaemic Injury

Post Intervention CABG or PCI

3. Non Ishaemic Cardiac Injury

Trononin Elevations Secondary Ischaemic Injury

Sympathomimetics

Pulmonary Embolism

Coronary Artery Spasm

Vasculitidies

End Stage Renal Failure

Acute Heart Failure

Extreme Endurance Exercise

Trononin Elevations Non Ishaemic Cardiac Injury

Myocarditis

Infection

Autoimmune

Drug induced

Toxins

Cardiac Trauma

Metabolic /Toxic

VISION

1933

2007

VISION Study

JAMA 2012;307 (21): 2295 -2304

Date of download: 9/4/2015 Copyright © 2015 American Medical Association. All

rights reserved.

From: Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac

Surgery

JAMA. 2012;307(21):2295-2304. doi:10.1001/jama.2012.5502

VISION Findings

15133 patients

24.2% > 75 years

51.5% Women

50.9% Hypertensive

19.5% Diabetes

26.5% Active cancer

(Orthopaedic 20.4%,Major General 20.3%, Low Risk 39.4%)

VISION Study

15133 Patients

282 deaths by 30 days (1.9%)

127 deaths Vascular

155 deaths Non-Vascular

Pneumonia day 6

Sepsis day 7

VISION Findings

TnT Level Percentage of Cohort 30 Day Mortality

0.01 ng/ml 88.4% 1.0%

0.02 ng/ml 3.3% 4.0%

0.03 -0.29 ng/ml 7.4% 9.3%

> 0.30 ng/ml 0.9% 16.9%

No Real effective with eGFR considered

VISION Study

Perioperative Troponin Elevations equated to mortality

Gradient of risk

Limitation of no pre-operative cTnT

? Maybe they were already sick

Background Elevated cTnT

Coronary Artery Disease

High-sensitive card iac troponin T and its rela tions to

card iovascular r isk factors, m orb id ity , and

m orta lity in elder ly m enKai M. Eggers, MD, PhD, a Jinan Al-Shakarchi, MD, a Lars Berglund, PhD, b Berti l Lindahl, MD, PhD, b

Agneta Siegbahn, MD, PhD, a Lars Wallentin, MD, PhD, b and Björn Zethelius, MD, PhD c Uppsala, Sweden

Back gr ound Cardiac troponin is emerging as risk indicator in community-dwelling populations. In this study, we

investigated the associations of cardiac troponin T (cTnT) to cardiovascular (CV) disease and outcome in elderly men.

M ethods Cardiac troponin T was measured using a high-sensitive assay in 940 men aged 71 years participating in the

Uppsala Longitudinal Study of Adult Men. We assessed both the cross-sectional associations of cTnT to CV risk factors and

morbidities including cancer and the longitudinal associations to outcomes over 10 years of follow-up.

Results Cardiac troponin T levels were measurable in 872 subjects (92.8%). In the cross-sectional analyses, cTnT was

associated to CV risk factors (diabetes, smoking, and obesity), renal dysfunction, CV disease including atrial fibrillation and

coronary artery disease, and biomarkers of inflammation and left ventricular dysfunction. In the longitudinal analyses, cTnT

independently predicted total mortality and CV events including stroke. The standardized adjusted hazard ratio regarding the

composite CV end point was 1.5 (95% CI 1.3-1.8), Pb .001, for men with prevalent CV disease and 1.2 (95% CI 1.0-1.4),

P= .02, for men without. Cardiac troponin T improved discrimination metrics for all outcomes in the total population. This was

mainly driven by the prognostic value of cTnT in subjects with prevalent CV disease.

Conclusions In community-dwelling men, cTnT levels are associated to CV risk factors and morbidities and predict both

fatal and nonfatal CV events. The relations to outcome are mainly seen in men with prevalent CV disease indicating that the

prognostic value of cTnT in subjects free from CV disease is limited. (Am Heart J 2013;166:541-548.e1.)

Traditional risk factors are useful to predict the

development of cardiovascular (CV) disease in commu-

nity-dwelling subjects but do not entirely explain the

interindividual variation in risk for CV events. Circulating

biomarkers are an important complement in this regard

as they might provide insights into pathophysiological

mechanisms that are not covered by traditional risk

factors. One of the most interesting biomarkers in this

context is cardiac troponin, commonly used as an

indicator of myocardial cell death in acute coronary

syndrome. Following improvements of assay sensitivity, it

has been shown that cardiac troponin levels may also be

measurable in the general population. In this setting,

troponin levels are indicative of chronic CV abnormali-

ties, for example, left ventricular hypertrophy, impaired

left ventricular systolic function, atrial fibrillation, and/or

myocardial ischemia due to stable coronary artery

disease,1-7 and predictive of adverse outcome.2-5,8-11

In the present study, we aimed to extend available

evidence regarding the implications of troponin levels in

the community by measuring cardiac troponin T (cTnT)

levelswith the use of ahigh-sensitive assay in elderly men.

We assessed both the cross-sectional associations to CV

risk factors and prevalent morbidities including cancer

and the longitudinal associations to outcomes over 10

years of follow-up.

M ethodsStudy population

The Uppsala Longitudinal Study of Adult Men (ULSAM) was

initiated in 1970. All 50-year-old men born between 1920 and

1924 and living in Uppsala, Sweden were invited to participate

in a health survey that focused on identifying CV risk factors

(described in detail at www.pubcare.uu.se/ULSAM). The

present analysis is based on the third examination cycle of the

ULSAM cohort that was conducted between 1991 and 1995

From the aDepartment of Medical Sciences, Uppsala University, Uppsala, Sweden,bUppsala Clinical Research Center, Uppsala University, Uppsala, Sweden, and cDepart-

ment of Public Health/ Geriatrics, Uppsala University and Medical Products Agency/

Epidemiology, Uppsala, Sweden.

Submitted February 7, 2013; accepted July 1, 2013.

Reprint requests: Kai M. Eggers, MD, PhD, Department of Medical Sciences, Cardiology,

Uppsala University, S-751 85 Uppsala, Sweden.

E-mail: [email protected]

0002-8703/ $ - see front matter

© 2013, Mosby, Inc. All rights reserved.

http:/ / dx.doi.org/ 10.101 6/ j.ahj.2013.07.004

Supplied for research and study purposes by Epworth HealthCare Library,

89 Bridge Road, Richmond Vic 3121 Date 2 September, 2015

The effect of age on hsTnT levels

A. Bima and K. Sikaris (2012) “Towards appreciating appropriate

clinical responses to highly sensitive cardiac troponin assays”

Intern Med J. Oct;42 Suppl 5:16-22.

Effect of older age on diagnostic and prognostic

per form ance of high-sensitiv ity troponin T in patients

presenting to an em ergency depar tm entJeanette Normann, MD, a Matthias Mueller, MD, a Moritz Biener, MD, Mehrshad Vafaie, MD, Hugo A. Katus, MD,

and Evangelos Giannitsis, MD Heidelber g, Ger many

Back gr ound The effect of age on diagnostic and prognostic performance of high-sensitivity cardiac troponin T(hs-cTnT)

has not been addressed adequately, so far.

M ethods High-sensitivity cardiac troponin T was measured serially in patients with acute symptoms presenting to our

emergency department. We tested the diagnostic and prognostic performance of baseline and serial hs-cTnT concentrations

related to age in all consecutive patients with acute coronary syndrome (ACS) (n = 342) or hs-cTnT increases not due to ACS

(n = 442).

Results Prevalence of elevated hs-cTnT in the study population was higher among patients ≥75 years compared with

younger patients (89.1 % vs 73.3 %, hazard ratio [HR] 1.2, Pb .0001). Elevated hs-cTnT was more likely due to ACS in the

younger patients (HR1.4, P= .001) and conversely more frequently due to non-ACS conditions in the elderly patients (HR1.3,

P= .0001). Diagnostic performance of hs-cTnT using the 99th percentile was significantly superior in younger than in elderly

patients (P b .0001). For receiver operating characteristic–optimized cutoffs, a trend to significance was found between

younger and older patients (area under the curve 0.87 vs 0.79, P = .074), with higher sensitivities (98.2 % vs 72.6%) and

negative predictive values (97.3% vs. 78.5%) for patients b75 years. Moreover, receiver operating characteristic–optimized

cutoff values for diagnosis of non–ST-segment elevation myocardial infarction were significantly higher in elderly patients (32.9

ng/ L) compared with younger patients (12.9 ng/ L). The prognostic information of single and serial hs-cTnT measurements was

comparably poor in both age groups, showing no better prognostic information to hs-cTnT measurement on presentation.

Conclusions Elevated hs-cTnT is more common in the elderly due to higher prevalence of non-ACS conditions and

significantly impairs diagnostic performance in discriminating non–ST-segment elevation myocardial infarction. (Am Heart J

2012;164:698-705.e4.)

Current European Society of Cardiology guidelines for

the management of acute coronary syndrome (ACS)

without ST-segment elevation promote the use of more

sensitive cardiac troponin (cTn) assaysas they allow more

accurate and earlier diagnosis of acute myocardial infarc-

tion (AMI) than previous less sensitive formulations.1

However, increased analytical sensitivity does not only

increase the detection rate of AMI but prompts identifica-

tion of a higher number of cTn elevations due to acute or

chronic cardiovascular pathologies including myocardial

damage unrelated to myocardial ischemia.2 Recently,

elevated cTn concentrations were detected in 24.4% of

hospitalized patients in a study using more sensitive cTn

assays, and most reasons for cTn elevations included non-

ACSconditions.3Accordingly, patientswith elevated cTnT

concentrations can also be found in departments other

than cardiology.3-5 In patients presenting acutely to an

emergency department (ED) with typical symptoms or

unequivocal electrocardiographic (ECG) changes, cTn

elevationsare most likely due to ACSconditions. However,

in the absence of a typical presentation, other acute

conditions such as pulmonary embolism, myocarditis,

takotsubo cardiomyopathy, tachycardias, or decompen-

sated valvular disease and numerous coexisting chronic

conditions including renal failure, chronic pulmonary

hypertension, and hypertensive heart disease must be

considered.1 The prevalence and reasons of elevated cTn

in a consecutive elderly population presenting to an ED

From the Department of Internal Medicine III, Cardiology, University Hospital Heidelberg,

Heidelberg, Germany.aBoth authors contributed equally to this work.

Submitted January 25, 2012; accepted August 14, 2012.

Reprint requests: Evangelos Giannitsis, MD, Medizinische Klinik III, Im Neuenheimer Feld

410, 69120 Heidelberg, Germany.

E-mail: [email protected]

0002-8703/ $ - see front matter

© 2012, Mosby, Inc. All rights reserved.

http:/ / dx.doi.org/ 10.101 6/ j.ahj.2012.08.003

Supplied for research and study purposes by Epworth HealthCare Library,

89 Bridge Road, Richmond Vic 3121 Date 2 September, 2015

Prevalence of Elevated Troponin: >75 y 89.1%, <75 y 73.3%

ACS more likely in Younger patient

Conclusion elevated cTnT in the elderly higher prevalence of Non ACS

AHJ, Vol 64 No 5 p698 2012

g

American Heart Journal

Volume 166, Issue 2, August 2013, Pages 325–332.e1

Clinical Investigation

High-sensitivity cardiac troponin T in prediction and diagnosis

of myocardial infarction and long-term mortality after

noncardiac surgery

Peter Nagele, MD, MSca, , g, , Frank Brown, BSca, g, Brian F. Gage, MD, MScc, g,

David W. Gibson, BSc, J. Philip Miller, ABc, d, g, Allan S. Jaffe, MDe, Fred S. Apple,

PhDa, f, Mitchell G. Scott, PhDb, g

Show more

Background

Perioperative myocardial infarction (MI) is a serious complication after noncardiac

surgery. We hypothesized that preoperative cardiac troponin T detected with a novel

high-sensitivity (hs-cTnT) assay will identify patients at risk for acute MI and long-term

mortality after major noncardiac surgery.

Methods

This was a prospective cohort study within the VINO trial (n = 608). Patients had been

diagnosed with or had multiple risk factors for coronary artery disease and underwent

major noncardiac surgery. Cardiac troponin I (contemporary assay) and troponin T (high-

sensitivity assay) and 12-lead electrocardiograms were obtained before and immediately

after surgery and on postoperative days 1, 2, and 3.

Results

At baseline before surgery, 599 patients (98.5%) had a detectable hs-cTnT

concentration, and 247 (41%) were >14 ng/L (99th percentile). After surgery, 497

patients (82%) had a rise in hs-cTnT (median change in hs-cTnT +2.7 ng/L [interquartile

range 0.7-6.8]). During the first 3 postoperative days, there were 9 patients (2.5%) with a

preoperative hs-cTnT <14 ng/L with acute MI, compared with 21 patients (8.6%) with a

preoperative hs-cTnT >14 ng/L (odds ratio 3.67, 95% CI 1.65-8.15). During long-term

follow-up, 80 deaths occurred. The 3-year mortality rate was 11% in patients with a

preoperative hs-cTnT concentration <14 ng/L compared with 25% in patients with a

preoperative hs-cTnT >14 ng/L (adjusted hazard ratio 2.17, 95% CI 1.19-3.96).

Conclusions

In this cohort of high-risk patients, preoperative hs-cTnT concentrations were

significantly associated with postoperative MI and long-term mortality after noncardiac

surgery.

Reprint requests: Peter Nagele, MD, MSc, Department of Anesthesiology, Washington University

School of Medicine, 660 S. Euclid Ave, Box 8054, St Louis, MO 63110.

VINO Study team members are listed under Acknowledgements.

Copyright © 2013 Mosby, Inc. All rights reserved.

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Pre-Operative cTnT Levels

Figure 2

American Heart Journal 2013 166, 325-332.e1DOI: (10.1016/j.ahj.2013.04.018)

Copyright © 2013 Mosby, Inc. Terms and Conditions

http://www.elsevier.com/termsandconditions



Figure 3






Figure 4






Supplementary Figure






So the way forward

1. No surgery for over 70 yo

2. All patients pre-operative cTnT

3. All patients a routine series of cTnt post operatively

4. Is this an area for Epworth Clinical research?

Sub selecting a certain procedure with a standard

age group

5. Or support your local interventional cardiologist and Cath them

all because “you can’t be sure”

Figure 1






Troponin Elevations in the Peri-operative Patient€¦ · Troponin Elevations in the Peri-operative Patient Associate Professor Ronald Dick . Case for Discussion 74 yo retired Anaesthetist

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