Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery
Por:
Devereaux, PJ, Chan, MTV, Alonso-Coello, P, Walsh, M, Berwanger, O, Villar, JC, Wang, CY, Garutti, RI, Jacka, MJ, Sigamani, A, Srinathan, S, Biccard, BM, Chow, CK, Abraham, V, Tiboni, M, Pettit, S, Szczeklik, W, Buse, GL, Botto, F, Guyatt, G, Heels-Ansdell, D, Sessler, DI, Thorlund, K, Garg, AX, Mrkobrada, M, Thomas, S, Rodseth, RN, Pearse, RM, Thabane, L, McQueen, MJ, VanHelder, T, Bhandari, M, Bosch, J, Kurz, A, Polanczyk, C, Malaga, G, Nagele, P, Le Manach, Y, Leuwer, M, Yusuf, S
Publicada:
6 jun 2012
Resumen:
Context Of the 200 million adults worldwide who undergo noncardiac surgery each year, more than 1 million will die within 30 days.
Objective To determine the relationship between the peak fourth-generation troponin T (TnT) measurement in the first 3 days after noncardiac surgery and 30-day mortality.
Design, Setting, and Participants A prospective, international cohort study that enrolled patients from August 6, 2007, to January 11, 2011. Eligible patients were aged 45 years and older and required at least an overnight hospital admission after having noncardiac surgery.
Main Outcome Measures Patients' TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We undertook Cox regression analysis in which the dependent variable was mortality until 30 days after surgery, and the independent variables included 24 preoperative variables. We repeated this analysis, adding the peak TnT measurement during the first 3 postoperative days as an independent variable and used a minimum P value approach to determine if there were TnT thresholds that independently altered patients' risk of death.
Results A total of 15 133 patients were included in this study. The 30-day mortality rate was 1.9% (95% CI, 1.7%-2.1%). Multivariable analysis demonstrated that peak TnT values of at least 0.02 ng/mL, occurring in 11.6% of patients, were associated with higher 30-day mortality compared with the reference group (peak TnT <= 0.01 ng/mL): peak TnT of 0.02 ng/mL (adjusted hazard ratio [aHR], 2.41; 95% CI, 1.33-3.77); 0.03 to 0.29 ng/mL (aHR, 5.00; 95% CI, 3.72-6.76); and 0.30 ng/mL or greater (aHR, 10.48; 95% CI, 6.25-16.62). Patients with a peak TnT value of 0.01 ng/mL or less, 0.02, 0.03-0.29, and 0.30 or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively. Peak TnT measurement added incremental prognostic value to discriminate those likely to die within 30 days for the model with peak TnT measurement vs without (C index=0.85 vs 0.81; difference, 0.4; 95% CI, 0.2-0.5; P<.001 for difference between C index values). The net reclassification improvement with TnT was 25.0% (P<.001).
Conclusion Among patients undergoing noncardiac surgery, the peak postoperative TnT measurement during the first 3 days after surgery was significantly associated with 30-day mortality. JAMA. 2012;307(21):2295-2304 www.jama.com
Filiaciones:
Devereaux, PJ:
McMaster Univ, Hamilton, ON, Canada
Chan, MTV:
Chinese Univ Hong Kong, Shatin, Hong Kong, Peoples R China
Alonso-Coello, P:
Biomed Res Inst St Pau IIB St Pau, Barcelona, Spain
Walsh, M:
McMaster Univ, Hamilton, ON, Canada
Berwanger, O:
Hosp Coracao, Res Inst HCor, Sao Paulo, Brazil
Villar, JC:
Univ Autonoma Bucaramanga, Bucaramanga, Colombia
Wang, CY:
Univ Malaya, Kuala Lumpur, Malaysia
Garutti, RI:
Hosp Gen Univ Gregorio Maranon, Madrid, Spain
Jacka, MJ:
Univ Alberta Hosp, Edmonton, AB, Canada
Sigamani, A:
St Johns Med Coll & Res Inst, Bangalore, Karnataka, India
Srinathan, S:
Univ Manitoba, Winnipeg, MB, Canada
Biccard, BM:
Univ Kwazulu Natal, Durban, South Africa
Chow, CK:
Univ Sydney, George Inst Global Hlth, Sydney, NSW, Australia
Abraham, V:
Christian Med Coll & Hosp, Ludhiana, Punjab, India
Tiboni, M:
McMaster Univ, Hamilton, ON, Canada
Pettit, S:
Hamilton Hlth Sci Ctr, Hamilton, ON, Canada
Szczeklik, W:
Jagiellonian Univ, Coll Med, Krakow, Poland
Buse, GL:
Populat Hlth Res Inst, Hamilton, ON, Canada
Botto, F:
Populat Hlth Res Inst, Hamilton, ON, Canada
Guyatt, G:
McMaster Univ, Hamilton, ON, Canada
Heels-Ansdell, D:
McMaster Univ, Hamilton, ON, Canada
Sessler, DI:
Cleveland Clin, Cleveland, OH USA
Thorlund, K:
McMaster Univ, Hamilton, ON, Canada
Garg, AX:
London Hlth Sci Ctr, London, ON, Canada
Mrkobrada, M:
London Hlth Sci Ctr, London, ON, Canada
Thomas, S:
Univ Rochester, Sch Med, Rochester, NY USA
Rodseth, RN:
Univ Kwazulu Natal, Durban, South Africa
Pearse, RM:
Barts & London Queen Marys Sch Med & Dent, London, England
Thabane, L:
McMaster Univ, Hamilton, ON, Canada
McQueen, MJ:
Hamilton Hlth Sci Ctr, Hamilton, ON, Canada
VanHelder, T:
Hamilton Hlth Sci Ctr, Hamilton, ON, Canada
Bhandari, M:
McMaster Univ, Hamilton, ON, Canada
Bosch, J:
McMaster Univ, Hamilton, ON, Canada
Kurz, A:
Cleveland Clin, Cleveland, OH USA
Polanczyk, C:
Univ Fed Rio Grande do Sul, Hosp Clin Porto Alegre, Porto Alegre, RS, Brazil
Malaga, G:
Univ Peruana Cayetano Heredia, Lima, Peru
Nagele, P:
Washington Univ, Sch Med, St Louis, MO USA
Le Manach, Y:
Hop La Pitie Salpetriere, Paris, France
Leuwer, M:
Royal Liverpool Broadgreen Univ Hosp Trust, Liverpool, Merseyside, England
Yusuf, S:
Populat Hlth Res Inst, Hamilton, ON, Canada
Bronze
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