The long-term impact of early cardiovascular therapy intensification for postoperative troponin elevation after major vascular surgery
Arnaud Foucrier1, Reitze Rodseth, Mohamed Aissaoui
1From the *Department of Anesthesiology and Critical Care, University Pierre et Marie-Curie-Paris 6, Assistance Publique-Hôpitaux de Paris, Paris, France; †Hospital Pitié-Salpétrière, Paris, France; ‡Department of Anaesthesia, Perioperative Research Group, University of KwaZulu-Natal, Pietermarizburg, South Africa; §The Perioperative Research Group, Population Health Research Institute, Hamilton, Ontario, Canada; ∥Biostatistical and Clinical Epidemiology Department, Faculty of Medicine, Nimes University Hospital, Montpellier 1 University, Montpellier, France; and ¶Departments of Anesthesia & Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University and Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Ontario, Canada.
Insights
Early evidence-based treatment for elevated troponin levels after vascular surgery can improve long-term cardiac outcomes. Prompt medical management following acute cardiac events in these patients may reduce mortality risk.
Area of Science:
- Cardiology
- Vascular Surgery
- Critical Care Medicine
Background:
- Acute cardiac events are a significant cause of morbidity following vascular surgery.
- The long-term impact of early, evidence-based treatment for these events remains understudied.
- Elevated postoperative cardiac troponin levels indicate an increased risk of adverse cardiac outcomes.
Purpose of the Study:
- To investigate the effect of evidence-based treatment on long-term outcomes in vascular surgery patients with elevated troponin levels.
- To determine if adhering to 2007 ACC/AHA guidelines for stable angina management improves patient survival.
- To assess the association between intensified cardiovascular treatment and major adverse cardiac events post-surgery.
Main Methods:
- A cohort study of 667 major vascular surgery patients with elevated postoperative troponin I.
- Assessment of medical therapy adherence based on 2007 ACC/AHA chronic stable angina guidelines.
- Matching of troponin-elevated patients with two control patients without troponin elevation using logistic regression and nearest-neighbor methods.
- Primary endpoint: 12-month survival without major cardiac events (death, MI, revascularization, pulmonary edema).
Main Results:
- Intensified cardiovascular treatment was given to 65% of patients with troponin I elevation.
- Patients with troponin elevation not receiving intensified treatment had a 1.77 HR for adverse outcomes compared to controls (P=0.004).
- Patients with troponin elevation receiving intensified treatment had an HR of 0.63 (P=0.45) compared to controls.
- Untreated patients faced a 2.80 HR for major cardiac events versus treated patients (P=0.04).
Conclusions:
- Elevated troponin I levels post-noncardiac surgery are linked to adverse long-term cardiac outcomes.
- Following evidence-based recommendations for acute coronary syndromes management can improve outcomes.
- Timely and appropriate medical management is crucial for reducing long-term cardiac risk in this patient population.
Background:
Acute cardiac events are a frequent cause of morbidity after vascular surgery. The impact of early evidence-based treatment for patients with an acute cardiac event after vascular surgery on long-term postoperative outcomes has not been extensively studied. We hypothesized that providing appropriate evidence-based treatment to patients with elevated postoperative cardiac troponin levels may limit long-term mortality.
Methods:
We conducted a study of 667 consecutive major vascular surgery patients with an elevated postoperative troponin I level. We then determined which of these patients received medical therapy as per the 2007 American College of Cardiology/American Heart Association recommendations for the medical management of patients with chronic stable angina. All patients with troponin elevation were then matched with 2 control patients without postoperative troponin elevation. Matching was done using logistic regression and nearest-neighbor matching methods. The primary study end point was 12 months survival without a major cardiac event (i.e., death, myocardial infarction, coronary revascularization, or pulmonary edema requiring hospitalization).
Results:
Therapy was intensified in 43 of 66 patients (65%) who suffered a troponin I elevation after surgery. Patients with a troponin I elevation not receiving intensified cardiovascular treatment had a hazard ratio (HR) of 1.77 (95% confidence interval (CI), 1.13-2.42; P = 0.004) for the primary study outcome as compared with the control group. In contrast, patients with a troponin I elevation who received intensified cardiovascular treatment had an HR of 0.63 (95% CI, 0.10-1.19; P = 0.45) for the primary outcome as compared with the control group. Patients with a troponin I elevation not receiving treatment intensification likely were at higher risk for a major cardiac event (HR, 2.80; 95% CI, 1.05-24.2; P = 0.04) compared with patients who did receive treatment intensification.
Conclusions:
The main finding of this study was that in patients with elevated troponin I levels after noncardiac surgery, long-term adverse cardiac outcomes may likely be improved by following evidence-based recommendations for the medical management of acute coronary syndromes.
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