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Myocardial injury and short- and long-term outcomes after oncological surgery: A large-scale retrospective cohort
Shaoyong Wu1, Xiong Song1, Yi Li1
1Department of Anesthesiology, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Center for Cancer, Sun Yat-sen University Cancer Center, Guangzhou, PR China.
Background:
Myocardial injury after noncardiac surgery (MINS) significantly contributes to perioperative mortality, yet its incidence and prognostic value in patients undergoing oncological surgery remain inadequately characterized.
Methods:
In this retrospective cohort study, we analyzed 6277 adults (mean age 58.9 years; 60.0 % male) undergoing intermediate-to-high-risk oncological surgeries between September 2013 and September 2022 with postoperative high-sensitivity troponin I (hsTnI) measurements. Dose-response relationships between peak hsTnI and the outcomes of 30-day mortality and 30-day major adverse cardiovascular events (MACE) were modeled using multivariable Cox regression with restricted cubic splines. MINS was defined as an ischemic hsTnI elevation >26 ng/L. Long-term (365-day) mortality was analyzed using both 30-day landmark analysis and flexible parametric survival model (FPSM) to account for potential time-varying effects.
Results:
Each standard deviation increase in log-transformed hsTnI was associated with a twofold higher risk of 30-day mortality (adjusted hazard ratio [aHR] 2.33, 95 % CI: 1.94-2.80; P < 0.001) and a nearly fourfold higher risk of 30-day MACE (aHR 3.91, 95 % CI: 3.47-4.42; P < 0.001). After excluding 22 patients with nonischemic troponin elevations, MINS occurred in 19.1 % of patients, with 98.7 % being asymptomatic. MINS independently predicted 30-day mortality (aHR 7.10, 95 % CI: 4.21-11.97; P < 0.001) and accounted for 53.8 % of the population-attributable risk. Adding MINS modestly improved the C-index for 30-day mortality prediction (0.831 vs. 0.797; ΔC-index, 0.034; P = 0.090) but significantly improved risk reclassification (net reclassification improvement, 31.51 %) and discrimination (integrated discrimination improvement, 0.037). Landmark analysis showed an 8.1-fold increased risk within 30 days and a sustained 1.8-fold risk from day 31 to 365. FPSM confirmed a sustained excess mortality hazard throughout the year.
Conclusions:
MINS is common, largely asymptomatic, and strongly associated with both early and late mortality after oncological surgery. Routine troponin monitoring may help identify high-risk patients for intervention.
