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Relation of Perioperative Elevation of Troponin to Long-Term Mortality After Orthopedic Surgery

      Myocardial necrosis in the perioperative period of noncardiac surgery is associated with short-term mortality, but long-term outcomes have not been characterized. We investigated the association between perioperative troponin elevation and long-term mortality in a retrospective study of consecutive subjects who underwent hip, knee, and spine surgery. Perioperative myocardial necrosis and International Classification of Disease, Ninth Revision–coded myocardial infarction (MI) were recorded. Long-term survival was assessed using the Social Security Death Index database. Logistic regression models were used to identify independent predictors of long-term mortality. A total of 3,050 subjects underwent surgery. Mean age was 60.8 years, and 59% were women. Postoperative troponin was measured in 1,055 subjects (34.6%). Myocardial necrosis occurred in 179 cases (5.9%), and MI was coded in 20 (0.7%). Over 9,015 patient-years of follow-up, 111 deaths (3.6%) occurred. Long-term mortality was 16.8% in subjects with myocardial necrosis and 5.8% with a troponin in the normal range. Perioperative troponin elevation (hazard ratio 2.33, 95% confidence interval 1.33 to 4.10) and coded postoperative MI (adjusted hazard ratio 3.51, 95% confidence interval 1.44 to 8.53) were significantly associated with long-term mortality after multivariable adjustment. After excluding patients with coronary artery disease and renal dysfunction, myocardial necrosis remained associated with long-term mortality. In conclusion, postoperative myocardial necrosis is common after orthopedic surgery. Myocardial necrosis is independently associated with long-term mortality at 3 years and may be used to identify patients at higher risk for events who may benefit from aggressive management of cardiovascular risk factors.
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      References

        • Steiner C.
        • Andrews R.
        • Barrett M.
        • Weiss A.
        HCUP Projections: Mobility/Orthopedic Procedures 2003 to 2012. Report # 2012-03.
        U.S. Agency for Healthcare Research and Quality; Rockville, MD, 2012 (Available at:) (Accessed on November 1, 2014)
        • Haralson III, R.H.
        • Zuckerman J.D.
        Prevalence, health care expenditures, and orthopedic surgery workforce for musculoskeletal conditions.
        JAMA. 2009; 302: 1586-1587
        • Weiss A.J.
        • Elixhauseer A.
        Trends in Operating Room Procedures in U.S. Hospitals, 2001–2011. HCUP Statistical Brief #171.
        Agency for Healthcare Research and Quality, Rockville, MD2014
        • Fleisher L.A.
        • Beckman J.A.
        • Brown K.A.
        • Calkins H.
        • Chaikof E.L.
        • Fleischmann K.E.
        • Freeman W.K.
        • Froehlich J.B.
        • Kasper E.K.
        • Kersten J.R.
        • Riegel B.
        • Robb J.F.
        • Smith Jr., S.C.
        • Jacobs A.K.
        • Adams C.D.
        • Anderson J.L.
        • Antman E.M.
        • Buller C.E.
        • Creager M.A.
        • Ettinger S.M.
        • Faxon D.P.
        • Fuster V.
        • Halperin J.L.
        • Hiratzka L.F.
        • Hunt S.A.
        • Lytle B.W.
        • Nishimura R.
        • Ornato J.P.
        • Page R.L.
        • Riegel B.
        • Tarkington L.G.
        • Yancy C.W.
        • American College of Cardiology
        • American Heart Association Task Force on Practice Guidelines
        • American Society of Echocardiography
        • American Society of Nuclear Cardiology
        • Heart Rhythm Society
        • Society of Cardiovascular Angiography
        • Society for Cardiovascular Angiography and Interventions
        • Society for Vascular Medicine and Biology
        • Society for Vascular Surgery
        ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on perioperative cardiovascular evaluation for noncardiac surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery.
        J Am Coll Cardiol. 2007; 50: e159-e241
        • Landesberg G.
        • Beattie W.S.
        • Mosseri M.
        • Jaffe A.S.
        • Alpert J.S.
        Perioperative myocardial infarction.
        Circulation. 2009; 119: 2936-2944
        • Adams III, J.E.
        • Bodor G.S.
        • Davila-Roman V.G.
        • Delmez J.A.
        • Apple F.S.
        • Ladenson J.H.
        • Jaffe A.S.
        Cardiac troponin I. A marker with high specificity for cardiac injury.
        Circulation. 1993; 88: 101-106
        • Thygesen K.
        • Alpert J.S.
        • Jaffe A.S.
        • Simoons M.L.
        • Chaitman B.R.
        • White H.D.
        • Thygesen K.
        • Alpert J.S.
        • White H.D.
        • Jaffe A.S.
        • Katus H.A.
        • Apple F.S.
        • Lindahl B.
        • Morrow D.A.
        • Chaitman B.R.
        • Clemmensen P.M.
        • Johanson P.
        • Hod H.
        • Underwood R.
        • Bax J.J.
        • Bonow J.J.
        • Pinto F.
        • Gibbons R.J.
        • Fox K.A.
        • Atar D.
        • Newby L.K.
        • Galvani M.
        • Hamm C.W.
        • Uretsky B.F.
        • Steg P.G.
        • Wijns W.
        • Bassand J.P.
        • Menasche P.
        • Ravkilde J.
        • Ohman E.M.
        • Antman E.M.
        • Wallentin L.C.
        • Armstrong P.W.
        • Simoons M.L.
        • Januzzi J.L.
        • Nieminen M.S.
        • Gheorghiade M.
        • Filippatos G.
        • Luepker R.V.
        • Fortmann S.P.
        • Rosamond W.D.
        • Levy D.
        • Wood D.
        • Smith S.C.
        • Hu D.
        • Lopez-Sendon J.L.
        • Robertson R.M.
        • Weaver D.
        • Tendera M.
        • Bove A.A.
        • Parkhomenko A.N.
        • Vasilieva E.J.
        • Mendis S.
        • Bax J.J.
        • Baumgartner H.
        • Ceconi C.
        • Dean V.
        • Deaton C.
        • Fagard R.
        • Funck-Brentano C.
        • Hasdai D.
        • Hoes A.
        • Kirchhof P.
        • Knuuti J.
        • Kolh P.
        • McDonagh T.
        • Moulin C.
        • Popescu B.A.
        • Reiner Z.
        • Sechtem U.
        • Sirnes P.A.
        • Tendera M.
        • Torbicki A.
        • Vahanian A.
        • Windecker S.
        • Morais J.
        • Aguiar C.
        • Almahmeed W.
        • Arnar D.O.
        • Barili F.
        • Bloch K.D.
        • Bolger A.F.
        • Botker H.E.
        • Bozkurt B.
        • Bugiardini R.
        • Cannon C.
        • de Lemos J.
        • Eberli F.R.
        • Escobar E.
        • Hlatky M.
        • James S.
        • Kern K.B.
        • Moliterno D.J.
        • Mueller C.
        • Neskovic A.N.
        • Pieske B.M.
        • Schulman S.P.
        • Storey R.F.
        • Taubert K.A.
        • Vranckx P.
        • Wagner D.R.
        • Joint ESCAAHAWHFTFfUDoMI
        • Authors/Task Force Members Chairpersons
        • Biomarker Subcommittee
        • Subcommittee ECG
        • Imaging Subcommittee
        • Classification Subcommittee
        • Intervention Subcommittee
        • Trials, Registries Subcommittee
        • Trials, Registries Subcommittee
        • Trials, Registries Subcommittee
        • Trials, Registries Subcommittee
        • Guidelines ESC Committee for Practice
        • Document Reviewers
        Third universal definition of myocardial infarction.
        J Am Coll Cardiol. 2012; 60: 1581-1598
        • Oberweis B.S.
        • Nukala S.
        • Rosenberg A.
        • Guo Y.
        • Stuchin S.
        • Radford M.J.
        • Berger J.S.
        Thrombotic and bleeding complications after orthopedic surgery.
        Am Heart J. 2013; 165: 427-433.e1
        • Jules-Elysee K.
        • Urban M.K.
        • Urquhart B.
        • Milman S.
        Troponin I as a diagnostic marker of a perioperative myocardial infarction in the orthopedic population.
        J Clin Anesth. 2001; 13: 556-560
        • Ausset S.
        • Auroy Y.
        • Lambert E.
        • Vest P.
        • Plotton C.
        • Rigal S.
        • Lenoir B.
        • Benhamou D.
        Cardiac troponin I release after hip surgery correlates with poor long-term cardiac outcome.
        Eur J Anaesthesiol. 2008; 25: 158-164
        • Urban M.K.
        • Jules-Elysee K.
        • Loughlin C.
        • Kelsey W.
        • Flynn E.
        The one year incidence of postoperative myocardial infarction in an orthopedic population.
        HSS J. 2008; 4: 76-80
        • Chong C.P.
        • Lam Q.T.
        • Ryan J.E.
        • Sinnappu R.N.
        • Lim W.K.
        Incidence of post-operative troponin I rises and 1-year mortality after emergency orthopaedic surgery in older patients.
        Age Ageing. 2009; 38: 168-174
        • Ausset S.
        • Auroy Y.
        • Verret C.
        • Benhamou D.
        • Vest P.
        • Cirodde A.
        • Lenoir B.
        Quality of postoperative care after major orthopedic surgery is correlated with both long-term cardiovascular outcome and troponin Ic elevation.
        Anesthesiology. 2010; 113: 529-540
        • Hietala P.
        • Strandberg M.
        • Kiviniemi T.
        • Strandberg N.
        • Airaksinen K.E.
        Usefulness of troponin T to predict short-term and long-term mortality in patients after hip fracture.
        Am J Cardiol. 2014; 114: 193-197
        • Devereaux P.J.
        • Chan M.T.
        • Alonso-Coello P.
        • Walsh M.
        • Berwanger O.
        • Villar J.C.
        • Wang C.Y.
        • Garutti R.I.
        • Jacka M.J.
        • Sigamani A.
        • Srinathan S.
        • Biccard B.M.
        • Chow C.K.
        • Abraham V.
        • Tiboni M.
        • Pettit S.
        • Szczeklik W.
        • Lurati Buse G.
        • Botto F.
        • Guyatt G.
        • Heels-Ansdell D.
        • Sessler D.I.
        • Thorlund K.
        • Garg A.X.
        • Mrkobrada M.
        • Thomas S.
        • Rodseth R.N.
        • Pearse R.M.
        • Thabane L.
        • McQueen M.J.
        • VanHelder T.
        • Bhandari M.
        • Bosch J.
        • Kurz A.
        • Polanczyk C.
        • Malaga G.
        • Nagele P.
        • Le Manach Y.
        • Leuwer M.
        • Yusuf S.
        • Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study Investigators
        Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery.
        JAMA. 2012; 307: 2295-2304
        • van Waes J.A.
        • Nathoe H.M.
        • de Graaff J.C.
        • Kemperman H.
        • de Borst G.J.
        • Peelen L.M.
        • van Klei W.A.
        Myocardial injury after noncardiac surgery and its association with short-term mortality.
        Circulation. 2013; 127: 2264-2271
        • Levy M.
        • Heels-Ansdell D.
        • Hiralal R.
        • Bhandari M.
        • Guyatt G.
        • Yusuf S.
        • Cook D.
        • Villar J.C.
        • McQueen M.
        • McFalls E.
        • Filipovic M.
        • Schunemann H.
        • Sear J.
        • Foex P.
        • Lim W.
        • Landesberg G.
        • Godet G.
        • Poldermans D.
        • Bursi F.
        • Kertai M.D.
        • Bhatnagar N.
        • Devereaux P.J.
        Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis.
        Anesthesiology. 2011; 114: 796-806
        • Oberweis B.S.
        • Berger J.S.
        In reply to the letter to the editor by Paul et al.
        Am Heart J. 2013; 165: e29
        • Dawson-Bowling S.
        • Chettiar K.
        • Cottam H.
        • Worth R.
        • Forder J.
        • Fitzgerald-O'Connor I.
        • Walker D.
        • Apthorp H.
        Troponin T as a predictive marker of morbidity in patients with fractured neck of femur.
        Injury. 2008; 39: 775-780
        • Fisher A.A.
        • Southcott E.N.
        • Goh S.L.
        • Srikusalanukul W.
        • Hickman P.E.
        • Davis M.W.
        • Potter J.M.
        • Budge M.M.
        • Smith P.N.
        Elevated serum cardiac troponin I in older patients with hip fracture: incidence and prognostic significance.
        Arch Orthop Trauma Surg. 2008; 128: 1073-1079
        • Lee T.H.
        • Marcantonio E.R.
        • Mangione C.M.
        • Thomas E.J.
        • Polanczyk C.A.
        • Cook E.F.
        • Sugarbaker D.J.
        • Donaldson M.C.
        • Poss R.
        • Ho K.K.
        • Ludwig L.E.
        • Pedan A.
        • Goldman L.
        Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery.
        Circulation. 1999; 100: 1043-1049
        • Sandoval Y.
        • Smith S.W.
        • Apple F.S.
        Type 2 myocardial infarction: the next frontier.
        Am J Med. 2014; 127: e19
        • Oberweis B.S.
        • Cuff G.
        • Rosenberg A.
        • Pardo L.
        • Nardi M.A.
        • Guo Y.
        • Dweck E.
        • Marshall M.
        • Steiger D.
        • Stuchin S.
        • Berger J.S.
        Platelet aggregation and coagulation factors in orthopedic surgery.
        J Thromb Thrombolysis. 2014; 38: 430-438
        • Adesanya A.O.
        • de Lemos J.A.
        • Greilich N.B.
        • Whitten C.W.
        Management of perioperative myocardial infarction in noncardiac surgical patients.
        Chest. 2006; 130: 584-596
        • Chong C.P.
        • van Gaal W.J.
        • Ryan J.E.
        • Profitis K.
        • Savige J.
        • Lim W.K.
        Does cardiology intervention improve mortality for post-operative troponin elevations after emergency orthopaedic-geriatric surgery? A randomised controlled study.
        Injury. 2012; 43: 1193-1198
        • Devereaux P.J.
        • Xavier D.
        • Pogue J.
        • Guyatt G.
        • Sigamani A.
        • Garutti I.
        • Leslie K.
        • Rao-Melacini P.
        • Chrolavicius S.
        • Yang H.
        • Macdonald C.
        • Avezum A.
        • Lanthier L.
        • Hu W.
        • Yusuf S.
        Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study.
        Ann Intern Med. 2011; 154: 523-528