Value of troponin measurements in carotid artery revascularization Gert J de Borst Department of Vascular Surgery
Postoperative myocardial infarction after NCS: Magnitude of the problem POISE-1: 367 /8,351= 4.4% VISION: 477/15,065= 3.2% POISE-2: 624/10,010= 6.2% POISE Study group, Lancet 2008 VISION Writing Group, Anesthesiology 2014 Devereaux et al, NEJM 2014 (2x)
Postoperative myocardial infarction: From preoperative prediction to postoperative detection Goldman Cardiac Risk Index (NEJM 1977) Revised Cardiac Risk Index (Circulation 1999) Insufficient predictive value Blunting perioperative stress response (beta-blockers and clonidine) or platelet inhibition (aspirin) (NEJM 1996, 1999, 2005, 2014 and Lancet 2008) Less myocardial infarctions, more strokes, deaths, bleeding and severe hypotension Early postoperative identification of myocardial damage by measuring troponin routinely after surgery (Circulation 2009, Anesthesiology 2011, JAMA 2012)
Levy, Anesthesiology 2011 Postoperative troponin elevation is associated with mortality
Elevated troponin after surgery associated with 30-day mortality ( dose-response ) 45% of 30-day mortality attributed to cardiovascular death Devereaux, JAMA 2012
Postoperative troponin elevation 80% within 3 days Biccard, Anesthesia 2010
In UMCU Non-cardiac surgery Age > 60 Postop admission > 24h Routine troponin monitoring 3 days postop Cardiac consult if troponin elevated
Risk of periprocedural MI in all randomized controlled trials comparing CAS and CEA CAS 0.75% (95% CI 0.31-1.39) CEA 1.87% (95% CI 0.84-3.31) Boulanger et al. Stroke 2015
Periprocedural Myocardial Infarction After Carotid Endarterectomy and Stenting Systematic Review and Meta-Analysis Marion Boulanger, MD; Lucie Camelière, MD; Rui Felgueiras, MD; Ludovic Berger, PhD; Kittipan Rerkasem, PhD; Peter M. Rothwell, PhD; Emmanuel Touzé, PhD
Kaplan-Meier survival curves after randomized carotid revascularization in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST). Joseph L. Blackshear et al. Circulation. 2011;123:2571-2578 Copyright American Heart Association, Inc. All rights reserved.
Routine Postoperative Troponin Measurements UMC Utrecht Cohort started in 2011 : Patients 60 years Intermediate to high risk surgery TnI measured once daily on POD 1,2,3 (threshold 60ng/L) No pre-op TnI! 2011-2012: N=4050 TnI measured: N= 3224 TnI elevated: N= 715 (22%)
Van Waes, Circulation 2013 Postoperative 30 day survival
Van Waes, Circulation 2013 One-year survival
Cause of death (1yr)
Cardiac Consultations
CASE 1: Postoperative MI in a patient undergoing carotid endarterectomy
Preoperative screening & early postoperative ECG Anterolateral ST depression
No chest pain, no dyspnea Physical examination HR 80 bpm RR 100/60 mmhg Saturation 93% +1L O2 Cor: S1S2 systolic murmur II/VI PM right IC 2 Postoperative lab Troponin: < 10 310 230 CK-MB: 6,2 9,8 10,1 Hb 4,9 Creat 60, GFR >90 Blood loss during surgery <200 ml
Diagnosis & Treatment Diagnosis: NSTEMI Treatment: 2 packed cells Metoprolol Telemetry Cardiac outpatient clinic in 1 month Follow-up: Echo: normal LV and RV function, calcified MV and AoV. No relevant valvular stenoses or regurgitations SPECT: no ischemia
What to do?
Clinical troponin cutoff 60 ng/l. Grobben RB et al. Clinical Relevance of Cardiac Troponin Assessment in Patients Undergoing Carotid Endarterectomy. EJVES 2016
Troponin elevation No Troponin elevation N=34 (15%) N = 191 (85%)
Clinical outcome during follow-up (Mean 20 M)
Clinical Relevance of Cardiac Troponin Assessment in Patients Undergoing Carotid Endarterectomy Tropinin I elevation in 15% of CEA patients. Silent non-stemi early postop phase Figure 2. Survival plots. Kaplan Meier survival plots for different clinical events after carotid endarterectomy, for groups with (dashed line) and without (continuous line) post-operative cardiac troponin elevation. A: major adverse cardiovascular events; B:... R. Grobben et al. European Journal of Vascular and Endovascular Surgery 2016
Further questions What causes postoperative MI? Prognostic factor? Causal factor? Can prognosis be improved? How to distinguish patients in whom prognosis can be improved?
Postoperative troponin elevation What is the problem? Why monitoring? What brings monitoring? What is next?