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. 2014 Mar;120(3):564-78.
doi: 10.1097/ALN.0000000000000113.

Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes

Fernando Botto  1 , Pablo Alonso-Coello, Matthew T V Chan, Juan Carlos Villar, Denis Xavier, Sadeesh Srinathan, Gordon Guyatt, Patricia Cruz, Michelle Graham, C Y Wang, Otavio Berwanger, Rupert M Pearse, Bruce M Biccard, Valsa Abraham, German Malaga, Graham S Hillis, Reitze N Rodseth, Deborah Cook, Carisi A Polanczyk, Wojciech Szczeklik, Daniel I Sessler, Tej Sheth, Gareth L Ackland, Martin Leuwer, Amit X Garg, Yannick Lemanach, Shirley Pettit, Diane Heels-Ansdell, Giovanna Luratibuse, Michael Walsh, Robert Sapsford, Holger J Schünemann, Andrea Kurz, Sabu Thomas, Marko Mrkobrada, Lehana Thabane, Hertzel Gerstein, Pilar Paniagua, Peter Nagele, Parminder Raina, Salim Yusuf, P J Devereaux, P J Devereaux, Daniel I Sessler, Michael Walsh, Gordon Guyatt, Matthew J McQueen, Mohit Bhandari, Deborah Cook, Jackie Bosch, Norman Buckley, Salim Yusuf, Clara K Chow, Graham S Hillis, Richard Halliwell, Stephen Li, Vincent W Lee, John Mooney, Carisi A Polanczyk, Mariana V Furtado, Otavio Berwanger, Erica Suzumura, Eliana Santucci, Katia Leite, Jose Amalth do Espirirto Santo, Cesar A P Jardim, Alexandre Biasi Cavalcanti, Helio Penna Guimaraes, Michael J Jacka, Michelle Graham, Finlay McAlister, Sean McMurtry, Derek Townsend, Neesh Pannu, Sean Bagshaw, Amal Bessissow, Mohit Bhandari, Emmanuelle Duceppe, John Eikelboom, Javier Ganame, James Hankinson, Stephen Hill, Sanjit Jolly, Andre Lamy, Elizabeth Ling, Patrick Magloire, Guillaume Pare, Deven Reddy, David Szalay, Jacques Tittley, Jeff Weitz, Richard Whitlock, Saeed Darvish-Kazim, Justin Debeer, Peter Kavsak, Clive Kearon, Richard Mizera, Martin O'Donnell, Matthew McQueen, Jehonathan Pinthus, Sebastian Ribas, Marko Simunovic, Vikas Tandon, Tomas Vanhelder, Mitchell Winemaker, Hertzel Gerstein, Sarah McDonald, Paul O'Bryne, Ameen Patel, James Paul, Zubin Punthakee, Karen Raymer, Omid Salehian, Fred Spencer, Stephen Walter, Andrew Worster, Anthony Adili, Catherine Clase, Deborah Cook, Mark Crowther, James Douketis, Azim Gangji, Paul Jackson, Wendy Lim, Peter Lovrics, Sergio Mazzadi, William Orovan, Jill Rudkowski, Mark Soth, Maria Tiboni, Rey Acedillo, Amit Garg, Ainslie Hildebrand, Ngan Lam, Danielle Macneil, Marko Mrkobrada, Pavel S Roshanov, Sadeesh K Srinathan, Clare Ramsey, Philip St John, Laurel Thorlacius, Faisal S Siddiqui, Hilary P Grocott, Andrew McKay, Trevor W R Lee, Ryan Amadeo, Duane Funk, Heather McDonald, James Zacharias, Juan Carlos Villar, Olga Lucía Cortés, Maria Stella Chaparro, Skarlett Vásquez, Alvaro Castañeda, Silvia Ferreira, Pierre Coriat, Denis Monneret, Jean Pierre Goarin, Cristina Ibanez Esteve, Catherine Royer, Georges Daas, Matthew T V Chan, Gordon Y S Choi, Tony Gin, Lydia C W Lit, Denis Xavier, Alben Sigamani, Atiya Faruqui, Radhika Dhanpal, Smitha Almeida, Joseph Cherian, Sultana Furruqh, Valsa Abraham, Lalita Afzal, Preetha George, Shaveta Mala, Holger Schünemann, Paola Muti, Enrico Vizza, C Y Wang, G S Y Ong, Marzida Mansor, Alvin S B Tan, Ina I Shariffuddin, V Vasanthan, N H M Hashim, A Wahab Undok, Ushananthini Ki, Hou Yee Lai, Wan Azman Ahmad, Azad H A Razack, German Malaga, Vanessa Valderrama-Victoria, Javier D Loza-Herrera, Maria De Los Angeles Lazo, Aida Rotta-Rotta, Wojciech Szczeklik, Barbara Sokolowska, Jacek Musial, Jacek Gorka, Pawel Iwaszczuk, Mateusz Kozka, Maciej Chwala, Marcin Raczek, Tomasz Mrowiecki, Bogusz Kaczmarek, Bruce Biccard, Hussein Cassimjee, Dean Gopalan, Theroshnie Kisten, Aine Mugabi, Prebashini Naidoo, Rubeshan Naidoo, Reitze Rodseth, David Skinner, Alex Torborg, Pilar Paniagua, Gerard Urrutia, Mari Luz Maestre, Miquel Santaló, Raúl Gonzalez, Adrià Font, Cecilia Martínez, Xavier Pelaez, Marta De Antonio, Jose Marcial Villamor, Jesús Alvarez García, Maria José Ferré, Ekaterina Popova, Pablo Alonso-Coello, Ignacio Garutti, Patricia Cruz, Carmen Fernández, Maria Palencia, Susana Díaz, Teresa Del Castillo, Alberto Varela, Angeles de Miguel, Manuel Muñoz, Patricia Piñeiro, Gabriel Cusati, Maria Del Barrio, Maria José Membrillo, David Orozco, Fidel Reyes, Robert J Sapsford, Julian Barth, Julian Scott, Alistair Hall, Simon Howell, Michaela Lobley, Janet Woods, Susannah Howard, Joanne Fletcher, Nikki Dewhirst, C Williams, A Rushton, I Welters, M Leuwer, Rupert Pearse, Gareth Ackland, Ahsun Khan, Edyta Niebrzegowska, Sally Benton, Andrew Wragg, Andrew Archbold, Amanda Smith, Eleanor McAlees, Cheryl Ramballi, Neil Macdonald, Marta Januszewska, Robert Stephens, Anna Reyes, Laura Gallego Paredes, Pervez Sultan, David Cain, John Whittle, Ana Gutierrez Del Arroyo, Daniel I Sessler, Andrea Kurz, Zhuo Sun, Patrick S Finnegan, Cameron Egan, Hooman Honar, Aram Shahinyan, Krit Panjasawatwong, Alexander Y Fu, Sihe Wang, Edmunds Reineks, Peter Nagele, Jane Blood, Megan Kalin, David Gibson, Troy Wildes; Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Writing Group, on behalf of The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Investigators; Appendix 1. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) Study Investigators Writing Group; Appendix 2. The Vascular events In noncardiac Surgery patIents cOhort evaluatioN Operations Committee; Vascular events In noncardiac Surgery patIents cOhort evaluatioN VISION Study Investigators
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Free article

Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes

Fernando Botto et al. Anesthesiology. 2014 Mar.
Free article

Abstract

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS.

Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria.

Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom.

Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

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