Perioperative Troponin Screening
Daniel I Sessler1, P J Devereaux
1From the *Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio; and †Population Health Research Institute and Departments of ‡Clinical Epidemiology and Biostatistics and §Medicine, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.
Insights
Routine troponin screening can detect silent myocardial injury after noncardiac surgery in patients 45 and older. Early detection and intervention significantly reduce mortality risk, making screening essential for this population.
Area of Science:
- Cardiology
- Perioperative Medicine
- Geriatric Surgery
Background:
- Myocardial injury is a leading cause of mortality within 30 days post-noncardiac surgery.
- A significant majority (65%) of perioperative myocardial infarctions are clinically silent, often missed without routine troponin screening.
- Asymptomatic troponin elevation carries a similar mortality risk to symptomatic elevation.
Purpose of the Study:
- To evaluate the necessity and impact of troponin screening for detecting myocardial injury in patients undergoing noncardiac surgery.
- To highlight the high mortality associated with postoperative troponin elevation and the benefits of early detection.
Main Methods:
- Analysis of perioperative myocardial infarction incidence and outcomes in noncardiac surgery patients.
- Assessment of the clinical presentation, including silent events, of myocardial injury.
- Calculation of the number needed to screen (NNS) to detect myocardial injury in specific patient demographics.
Main Results:
- Postoperative troponin elevation is associated with a 10% 30-day mortality, a five-fold increase in risk.
- The number necessary to screen to detect otherwise missed myocardial injury in surgical inpatients aged 45 and older is approximately 15.
- Routine troponin screening is deemed appropriate for most surgical inpatients aged 45 and above.
Conclusions:
- Troponin screening is a valuable tool for identifying silent myocardial injury in the perioperative setting.
- Early detection enables timely interventions, potentially improving outcomes and reducing mortality.
- Screening surgical patients aged 45 and older for myocardial injury is cost-effective and clinically indicated.
Abstract:
Myocardial injury is the most common cause of death during the 30 days after noncardiac surgery. Only 14% of patients who are experiencing a perioperative myocardial infarction will have chest pain, and 65% are entirely clinically silent, which means that they will go undetected without routine troponin screening. Although it is tempting to dismiss asymptomatic troponin elevation, mortality is similar with and without symptoms. Furthermore, mortality at 30 days in patients who have postoperative troponin elevation is a concerning 10%, which represents a 5-fold increase from background risk. Among inpatients ≥45 years of age who are having noncardiac surgery, the number necessary to screen to detect myocardial injury after noncardiac surgery, that would otherwise be missed, is only about 15 patients. Thus, troponin screening seems appropriate for most surgical inpatients who are ≥45 years of age. Potential acute interventions include initiating therapy such as aspirin, statins, and angiotensin-converting enzyme (ACE) inhibitor antihypertensives, along with chronic lifestyle improvements such as smoking cessation, healthful eating, and exercise.
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