Association between occurrence time of myocardial injury after noncardiac surgery and long-term functional capacity: a secondary analysis of a prospective study

Increasing the Perioperative Specialists Role: Comment on the 2021 American Heart Association Scientific Statement on Myocardial Injury After Noncardiac Surgery

The Silent Burden of Perioperative Myocardial Infarction After Noncardiac Surgery

The objective of this study was to determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in major general surgery patients. MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in major general surgical patients have not been described. This was an international prospective cohort study of a representative sample of 22,552 noncardiac surgery patients 45 years or older, of whom 4490 underwent major general surgery in 24 centers in 13 countries. All patients had fifth-generation plasma high-sensitivity troponin T (hsTnT) concentrations measured during the first 3 postoperative days. MINS was defined as a hsTnT of 20-65ng/L and absolute change >5ng/L or hsTnT ≥65ng/L secondary to ischemia. The objectives of the present study were to determine (1) whether MINS is prognostically important in major general surgical patients, (2) the clinical characteristics of major general surgical patients with and without MINS, (3) the 30-day outcomes for major general surgical patients with and without MINS, and (4) the proportion of MINS that would have gone undetected without routine postoperative monitoring. The incidence of MINS in the major general surgical patients was 16.3% (95% CI, 15.3-17.4%). Thirty-day all-cause mortality in the major general surgical cohort was 6.8% (95% CI, 5.1%-8.9%) in patients with MINS compared with 1.2% (95% CI, 0.9%-1.6%) in patients without MINS ( P <0.01). MINS was independently associated with 30-day mortality in major general surgical patients (adjusted odds ratio 4.7, 95% CI, 3.0-7.4). The 30-day mortality was higher both among MINS patients with no ischemic features (ie, no ischemic symptoms or electrocardiogram findings) (5.4%, 95% CI, 3.7%-7.7%) and among patients with 1 or more clinical ischemic features (10.6%, 95% CI, 6.7%-15.8%). The proportion of major general surgical patients who had MINS without ischemic symptoms was 89.9% (95% CI, 87.5-92.0). Approximately 1 in 6 patients experienced MINS after major general surgery. MINS was independently associated with a nearly 5-fold increase in 30-day mortality. The vast majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.

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. 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. 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%). 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. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Introduction: Myocardial Injury after Non-Cardiac Surgery (MINS) is a significant cause of perioperative morbidity and mortality. Recognizing and understanding the patient characteristics and potential predictors of MINS can contribute to more effective patient risk stratification and management. Hypothesis: Certain preoperative risk factors are associated with a higher risk of developing MINS among patients undergoing noncardiac surgery. Methods: We retrospectively reviewed the data on 2458 noncardiac surgeries performed within the MedStar System between 2022-2023 in which patients underwent routine pre- and postoperative high sensitivity troponin I (hsTnI) and EKG monitoring over 72 hours. MINS was defined as any elevation in hsTnI &gt;99 th percentile for gender (&gt;34 ng/L: females, &gt;53 ng/L :males). Multivariable logistic regression models were used to identify the factors associated with MINS which included demographics, surgical details, comorbidities, relevant preoperative labs and vitals. Results: Out of the 2,458 patients, 889 (36%) were diagnosed with MINS. Patients with MINS were older, nonsmokers, and females with prior congestive heart failure (CHF), coronary artery disease (CAD), chronic kidney disease (CKD), atrial fibrillation, and preoperatively lower blood pressure and higher creatinine compared to patients without MINS (Table 1). In multivariable adjusted models, CHF [aOR=1.6, 95%CI: (1.1, 2.3)], CAD [aOR=2.1(14, 2.9)], CKD [aOR=1.4(1.2, 1.8)] were associated with higher odds of developing MINS. RCRI score was not associated with postop MINS. Figure 1 shows rates of developing MINS among surgical specialties. Conclusions: Our study demonstrates that risk factors including age, gender, pre-existing cardiovascular and renal disease, preoperative blood pressure, and certain surgery types are associated with MINS. Research is needed to further define how to utilize this information to identify and minimize the risk of MINS.

To determine the prognostic relevance, clinical characteristics, and 30-day outcomes associated with myocardial injury after noncardiac surgery (MINS) in vascular surgical patients. MINS has been independently associated with 30-day mortality after noncardiac surgery. The characteristics and prognostic importance of MINS in vascular surgery patients are poorly described. This was an international prospective cohort study of 15,102 noncardiac surgery patients 45 years or older, of whom 502 patients underwent vascular surgery. All patients had fourth-generation plasma troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a TnT of 0.03 ng/mL of higher secondary to ischemia. The objectives of the present study were to determine (i) if MINS is prognostically important in vascular surgical patients, (ii) the clinical characteristics of vascular surgery patients with and without MINS, (iii) the 30-day outcomes for vascular surgery patients with and without MINS, and (iv) the proportion of MINS that probably would have gone undetected without routine troponin monitoring. The incidence of MINS in the vascular surgery patients was 19.1% (95% confidence interval (CI), 15.7%-22.6%). 30-day all-cause mortality in the vascular cohort was 12.5% (95% CI 7.3%-20.6%) in patients with MINS compared with 1.5% (95% CI 0.7%-3.2%) in patients without MINS (P < 0.001). MINS was independently associated with 30-day mortality in vascular patients (odds ratio, 9.48; 95% CI, 3.46-25.96). The 30-day mortality was similar in MINS patients with (15.0%; 95% CI, 7.1-29.1) and without an ischemic feature (12.2%; 95% CI, 5.3-25.5, P = 0.76). The proportion of vascular surgery patients who suffered MINS without overt evidence of myocardial ischemia was 74.1% (95% CI, 63.6-82.4). Approximately 1 in 5 patients experienced MINS after vascular surgery. MINS was independently associated with 30-day mortality. The majority of patients with MINS were asymptomatic and would have gone undetected without routine postoperative troponin measurement.

Myocardial injury after non-cardiac surgery (MINS) has been recently defined as troponin elevation ≥0.03ng/ml, associated with 3.87 fold increase in early mortality (1). We sought to determine the impact of early cardiology intervention on 30-day mortality in patients who underwent general thoracic surgery and developed MINS. Methods: A retrospective review of patients who underwent thoracic surgery over a 5-year period where troponin levels were routinely measured on the first post-operative day was performed. Data acquisition and mortality status was obtained via medical records and NHS tracing systems. Thirty-day mortality was compared on the MINS cohort using Fisher’s exact square testing and logistic regression analysis. Actuarial survival was calculated using Kaplan Meier method and Cox proportional hazards regression was utilized to determine risk adjusted impact of MINS on post-operative survival. Results: Troponin levels were measured in 492 (96%) of 511 patients and 80 (16%) had troponin elevation fulfilling MINS criteria. Of the MINS positive patients, 61 (76%) received early cardiology consult and a formal diagnosis of “myocardial infarction” stated in 4 (5%). Risk assessment for Acute Myocardial Infarction was performed in all patients and 20 (25%) commenced on anti-platelet agents, 4 (5%) on β-blockers and 1 (1%) underwent primary coronary intervention. In total, 49 (61%) received primary risk factor modification and 26 (33%) had further cardiology outpatient follow-up. There were no significant differences in the proportion who died within the first 30 days in the MINS group (2.6%) compared to the non-MINS group (1.6%; P=0.625). The odds ratio for 30-day mortality in the MINS group was 1.69 (95% CI 0.34 to 8.57, P=0.522). On follow up there were no significant difference on the impact of MINS on survival between the two groups (HR 1.06 95% CI 0.67 to 1.68; P=0.799). Conclusion: Our results confirm MINS is common after general thoracic surgery. We observed that early cardiology intervention reduced the expected hazard ratio of early death from 3.87 to an odds ratio of 1.69 with no significant difference in either early or longer term mortality for patients who developed MINS.

Myocardial injury after non-cardiac surgery (MINS) is common. We investigated the incidence and outcomes of MINS, and mechanistic underpinnings using pre-operative whole blood gene expression profiling in a prospective cohort study of individuals undergoing lower extremity revascularization (LER) for peripheral artery disease (PAD). Major adverse cardiovascular and limb events (MACLE) were defined as a composite of death, myocardial infarction, stroke, major lower extremity amputation or reoperation. Among 226 participants undergoing LER, MINS occurred in 53 (23.5%). Patients with MINS had a greater incidence of major adverse cardiovascular events (49.1% vs. 22.0%, adjusted HR 1.87, 95% CI 1.07–3.26) and MACLE (67.9% vs. 44.5%; adjusted HR 1.66, 95% CI 1.08–2.55) at median 20-month follow-up. Pre-operative whole blood transcriptome profiling of a nested matched MINS case–control cohort (n = 41) identified upregulation of pathways related to platelet alpha granules and coagulation in patients who subsequently developed MINS. Thrombospondin 1 (THBS1) mRNA expression was 60% higher at baseline in patients who later developed MINS, and was independently associated with long-term cardiovascular events in the Duke Catheterization Genetics biorepository cohort. In conclusion, pre-operative THBS1 mRNA expression is higher in patients who subsequently develop MINS and is associated with incident cardiovascular events. Pathways related to platelet activity and coagulation associated with MINS provide novel insights into mechanisms of myocardial injury.

BackgroundThe atherogenic index of plasma (AIP) is a reliable lipid marker associated with coronary artery stenosis (CAS) and cardiovascular events. However, the relationship between AIP and myocardial injury after non-cardiac surgery (MINS) remains insufficiently explored.MethodsThis retrospective study included adult patients who underwent non-cardiac surgery under general anaesthesia. The primary exposure was preoperative AIP, with MINS as the primary outcome. The predictive accuracy of AIP for MINS was assessed using the area under the curve (AUC). Restricted cubic splines (RCS) were used to explore the potential nonlinear relationship between AIP and MINS. Logistic regression analysis was conducted to examine the association of AIP with MINS. Subgroup and interaction analyses were carried out across multiple factors, including age, gender, body mass index, medical history, and the type of surgery (emergency or elective).ResultsThe cohort consisted of 1,160 adult patients, with a median preoperative AIP of -0.05. The incidence of MINS was 7.9%. The AUC for AIP in predicting MINS was 0.719, surpassing the AUCs of triglycerides and high-density lipoprotein cholesterol (0.644 and 0.683, respectively). RCS analysis demonstrated a linear relationship between AIP and MINS (P for nonlinear = 0.165). Patients in the highest quartile of AIP had significantly higher odds of developing MINS than those in the lowest quartile (adjusted OR, 8.05; 95% confidence interval [CI], 3.44 to 18.80; P < 0.001). The results across most subgroups were consistent with the primary analysis, showing no significant interaction effects.ConclusionsA significant and independent linear relationship exists between preoperative AIP and the risk of MINS. As an economical and easily accessible lipid marker, AIP holds potential for preoperative screening of patients at risk of postoperative cardiovascular events.

HighlightsAcute perioperative myocardial injury develops in 38.5% of patients with non – small cell lung cancer and is associated with the ThRCRI major cardiac events risk index, preoperative hemoglobin level and postoperative heart rate. Aim. To determine the incidence and predictors of acute myocardial injury after surgical treatment of patients with non – small cell lung cancer (NSCLC).Methods. The study included 104 men aged 63.0 [58–67] years who underwent lung resection for NSCLC. Blood levels of cardiac troponin I (cTnI) were determined before and 24 and 48 hours after surgery. Myocardial injury after noncardiac surgery (MINS) was diagnosed when postoperative cTnI increased &gt; 99th percentile of the upper reference limit. Two patients with elevated cTnI of non-ischemic origin were excluded from the analysis. In groups with and without MINS, clinical parameters were compared and their relationships with the MINS development were assessed using univariate regression. Multivariate logistic regression analysis was performed to identify independent MINS predictors. ROC curves were constructed and threshold values of quantitative variables associated with the study outcome were determined.Results. MINS was diagnosed in 40 patients (38.5%). In 36 of them, the cTnI increase was asymptomatic. Among patients with MINS, in contrast to the group without MINS, the share of pneumonectomy, heart rate (HR) after surgery and the cardiac events risk index ThRCRI were higher, as well as hemoglobin level before surgery was lower. Using multiple logistic regression, a combination of factors that provides the greatest accuracy in predicting MINS was identified: ThRCRI index ≥ 1 (adjusted odds ratio (OR) 5.85, 95% confidence interval [1.41–24.28]), hemoglobin before surgery (OR 0.68 [0.5–0.91] for every 10 g/L), HR after surgery (OR 1.99 [1.26–3.13] for every 10 min–1). Threshold levels were established for hemoglobin before surgery (135 g/L), below which the OR for MINS was 2.54 [1.12–5.75], and postoperative HR (88 min–1), above which the OR for MINS was 2.64 [1.16–5.99].Conclusion. The incidence of acute myocardial injury after NSCLC surgery is 38.5%. In 90% of cases the MINS was asymptomatic. A mathematical model was created and following independent predictors of MINS were established: ThRCRI index ≥ 1, hemoglobin level before and heart rate after the surgery. At a threshold hemoglobin value &lt; 135 g/L and HR&gt;88 min–1, the risk of MINS increases significantly.

Background and Aims: Myocardial Injury after Noncardiac Surgery (MINS) is a broader term that includes not only perioperative myocardial infarction but also other prognostically significant myocardial injuries due to ischemia, within 30 days after noncardiac surgery. Annually, around 1 million patients who undergo noncardiac surgery worldwide die during the first 30 days following surgery. The incidence of MINS is around 5-8%, with the majority occurring in the first two days after surgery. A recent study showed a potential positive effect of Dabigatran to prevent major vascular complications among patients with MINS. However, until now there is no evidence related to whether any effective drug may reduce its incidence. Our study aims to assess the efficacy of dabigatran to prevent MINS in a high cardiovascular risk population. Methods: This study will be a multicenter randomized, two-arms (1:1 ratio), active-controlled and double-dummy, phase II trial. We will study 264 adults (45-75 years) with a high cardiovascular risk, assessed by the Framingham Risk Score, who are undergoing elective orthopedic surgery. Patients which troponin measurement keeps negative after surgery will be randomly assigned (1:1) to receive dabigatran 150mg twice daily or enoxaparin daily, 6 hours after surgery for seven days. The primary outcome will be the incidence of MINS as ascertained by the difference in troponin (troponin delta) greater than 14ng/L in the perioperative period, after randomization. Secondary outcomes will be 30-day mortality, major thromboembolic complications, and severe bleeding complications. The potential impact of the study: This clinical trial will be the first to assess the efficacy and the safety of dabigatran to prevent MINS. Given MINS is estimated to affect every year about 8 million patients worldwide and is associated with cardiovascular complications and death after surgery, we believe this trial will provide relevant data to clinical practice and future research directions.

Objective: The role of preoperative echocardiography at rest is less well studied. We analyzed the prognostic value of left ventricular global longitudinal strain (LVGLS) for predicting postoperative 30-day cardiovascular events and myocardial injury after noncardiac surgery (MINS). Design and method: We performed a prospective cohort study in two referral hospitals enrolling participants over 45-year-old with more than one cardiovascular risk factor or 65-year-old aged who planned elective noncardiac major surgery and underwent resting echocardiography before surgery. Preoperative demographic, clinical, and echocardiographic data, including LVGLS, were collected. Subjects with minor surgery, reduced ejection fraction below 40%, more than moderate valvular heart disease, and presence of regional wall motion abnormality were excluded. The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, and acute coronary syndrome (ACS) needing urgent revascularization at early postoperative period. MINS was defined as absolute increase troponin of at least 14 pg/mL between two measurements. Results: From 2020 June to 2022 March, 871 participants were enrolled; the mean age was 72.9 (SD 9.3) and 60.8% were female. There were 12 cases of the primary endpoint (1.4%): 10 cases of death, and 3 cases of revascularization due to ACS. Participants with impaired LVGLS &lt;16.6% had a higher incidence of the primary endpoint (log-rank P = 0.015) than those without. This result was concordant after adjustment with clinical variable and preoperative troponin-T level (hazard ratio 1.30, 95% confidence interval [CI] 1.03–1.65; P = 0.027). In sequential Cox analysis and net reclassification index, LVGLS had incremental value for predicting the primary endpoint after noncardiac surgery. Among 538 (61.8%) participants available pre and post-troponin assay, LVGLS can predict MINS independently (odds ratio 3.54, 95% CI 1.70–7.36; P = 0.001). Conclusions: Preoperative LVGLS has independent and incremental value to predict early postoperative cardiovascular events and MINS.

Evaluation of perioperative troponin levels as a prognostic factor for morbidity/mortality following hepato-pancreato-biliary surgery: early outcomes

Myocardial injury after noncardiac surgery (MINS) is associated with increased perioperative mortality; however, the incidence and prognostic impact of MINS after major head and neck surgery remains uncertain. To determine the incidence and clinical implications of MINS in patients after major head and neck surgery. This cohort study used data from the VISION (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation; 2017) study, an international prospective cohort study that analyzed more than 35 000 patients who had noncardiac surgery. Of those, 648 patients (1.8%) underwent major head and neck surgery requiring at least 1-day hospital admission and screening for MINS via troponin T (TnT) concentrations measured during the first 3 postoperative days. MINS was defined as a high-sensitivity TnT (hsTnT) of 20 to 64 ng/L and absolute change more than 5 ng/L or hsTnT 65 ng/L or greater (ie, fifth-generation assay) and cardiac ischemia. When using fourth-generation assay, MINS was defined as non-hsTNT 0.04 ng/mL or greater and cardiac ischemia. Data analyses were performed from October to December 2024. MINS incidence and its association with 30-day mortality. All clinical outcomes were analyzed using Cox regression models and length of hospital stay (LOHS) was analyzed using multivariable linear regression. Among 648 patients (265 [40.9%] female and 383 [59.1%] male; 376 [58.0%] aged 45 to 64 years), the incidence of MINS after major head and neck surgery was 11.9% (95% CI, 9.39%-14.4%), rising to 23.8% (95% CI, 15.7%-32%) among those aged 75 years or older. MINS occurred more often in patients with medical comorbidities. The proportion of MINS that would have gone undetected without TnT monitoring was 68.8% (95% CI, 57.3%-78.9%). In this cohort, 30-day and 1-year mortality were 1.9% (95% CI, 0.8%-2.9%) and 13.1% (95% CI, 10.5%-15.7%), respectively. MINS was associated with increased 30-day mortality (hazard ratio, 5.51; 95% CI, 1.75-17.36) and prolonged LOHS in patients with MINS with at least 1 ischemic feature (adjusted β, 3.15 days; 95% CI, 1.47-6.76 days). This cohort study found that myocardial injury was common among patients undergoing major head and neck surgery, especially those aged 75 years or older and those with comorbidities. Nearly 70% of MINS cases go undetected without TnT monitoring, and MINS may contribute to worse 30-day postoperative mortality and prolonged LOHS. Further prospective validation is needed to evaluate the role of MINS screening in improving clinical outcomes after major head and neck surgery.

Recent investigations have substantially improved our understanding of myocardial injury after noncardiac surgery (MINS). MINS is defined as a prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. MINS occurs in 8% of adults undergoing major noncardiac surgery and is diagnosed with an elevated postoperative troponin measurement. MINS is associated with significant morbidity, and approximately 10% of patients experiencing MINS will die within 30 days. There is a dose-graded response in mortality and time to death with increasing levels of postoperative troponin elevations. Most patients (>80%) suffering from MINS will not experience an ischemic symptom. Without troponin monitoring, the majority of MINS events would go undetected. To avoid missing these prognostically relevant events, guidelines now recommend perioperative troponin monitoring in high-risk patients having noncardiac surgery. In patients who suffer MINS, risk-adjusted observational data suggest that aspirin and a statin can reduce the risk of 30-day mortality. Among adults, MINS is the most common cardiovascular complication that occurs after noncardiac surgery. Given that worldwide 200 million adult patients undergo major noncardiac surgery each year, at least 8 million of these patients will suffer MINS making this a substantial public health problem.