The Journal of Bone and Joint Surgery; May 20, 2020; 102 (10): 880

Association Between Myocardial Injury and Cardiovascular Outcomes of Orthopaedic Surgery

Thomas Sabu, MD, MSc; Borges Flavia, MD, PhD; Bhandari Mohit, MD, PhD; De Beer Justin, MD; Urrútia Cuchí Gerard, MD; Adili Anthony, MD; Winemaker Mitchell, MD; Avram Victoria, MD; Chan Matthew T. V., MD; Lamas Claudia, MD, PhD; Cruz Patricia, MD; Aguilera Xavier, MD; Garutti Ignacio, MD; Alonso-coello Pablo, MD; Villar Juan Carlos, MD; Jacka Michael, MD, MSc; Wang C. Y., MD; Berwanger Otavio, MD; Chow Clara, MD, PhD; Srinathan Sadeesh, MD; Pettit Shirley, RN; Heels-ansdell Dianne, PhD; Rubery Paul, MD; Devereaux P. J., MD, PhD
Hip Knee
Background: Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia.
Methods: We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom.
Results: Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%).
Conclusions: One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements.
Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

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