Post on 19-Aug-2020
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: kai.eggers@ucr.uu.se
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: evangelos_giannitsis@med.uni-heidelberg.de
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.
0 0 0 00 0 0 0
00
0 0 00 0 0
0 0 0 0 0 0) 0) 0
( 0
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
Figure 3
American Heart Journal 2013 166, 325-332.e1DOI: (10.1016/j.ahj.2013.04.018)
Copyright © 2013 Mosby, Inc. Terms and Conditions
Figure 4
American Heart Journal 2013 166, 325-332.e1DOI: (10.1016/j.ahj.2013.04.018)
Copyright © 2013 Mosby, Inc. Terms and Conditions
Supplementary Figure
American Heart Journal 2013 166, 325-332.e1DOI: (10.1016/j.ahj.2013.04.018)
Copyright © 2013 Mosby, Inc. Terms and Conditions
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
American Heart Journal 2013 166, 325-332.e1DOI: (10.1016/j.ahj.2013.04.018)
Copyright © 2013 Mosby, Inc. Terms and Conditions