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CLINICAL RESEARCH

Cardiac troponin after major vascular surgery

The role of perioperative ischemia, preoperative thallium scanning, and coronary revascularization

Giora Landesberg, MD, DSc^*,*, Morris Mosseri, MD, Vadim Shatz, MD^*, Inna Akopnik, MD, Moshe Bocher, MD, Michael Mayer, DSc^||, Haim Anner, MD, Yacov Berlatzky, MD and Charles Weissman, MD^*

^* Department of Anesthesiology and CCM, The Hebrew University and Hadassah Medical Center, Jerusalem, Israel
Department of Cardiology, The Hebrew University and Hadassah Medical Center, Jerusalem, Israel
Department of Vascular Surgery, The Hebrew University and Hadassah Medical Center, Jerusalem, Israel
Department of Nuclear Medicine, The Hebrew University and Hadassah Medical Center, Jerusalem, Israel
^|| Department of Clinical Biochemistry, The Hebrew University and Hadassah Medical Center, Jerusalem, Israel

Manuscript received January 16, 2004; revised manuscript received March 8, 2004, accepted March 11, 2004.

^* Reprint requests and correspondence: Dr. Giora Landesberg, Department of Anesthesiology and CCM, Hadassah University Hospital, Jerusalem, Israel 91120.
gio{at}cc.huji.ac.il

OBJECTIVES: We sought to determine the role of preoperative predictors, particularly ischemia, on preoperative thallium scanning (PTS) and coronary revascularization on low-level and conventional troponin elevations after major vascular surgery.

BACKGROUND: Postoperative cardiac troponin (cTn) elevations have recently been shown to predict both short- and long-term mortality after vascular surgery.

METHODS: The perioperative data, including PTS and subsequent coronary revascularization, continuous perioperative 12-lead ST-segment trend monitoring, cTn-I and/or cTn-T, and creatine kinase-MB fraction in the first three postoperative days, were prospectively collected in 501 consecutive elective major vascular procedures.

RESULTS: Moderate to severe inducible ischemia on PTS was associated with a 49.0% incidence of low-level (cTn-I >0.6 and/or cTn-T >0.03 ng/ml) and 22.4% conventional (cTn-I >1.5 and/or cTn-T >0.1 ng/ml) troponin elevation. In contrast, patients with preoperative coronary revascularization had 23.4% and 6.4% low-level and conventional troponin elevations, respectively, similar to patients without ischemia on PTS. By multivariate logistic regression, ischemia on PTS was the most important predictor of both low-level and conventional troponin elevations (adjusted odds ratios [ORs] 2.5 and 2.7, p = 0.02 and 0.04, respectively), whereas preoperative coronary revascularization predicted less troponin elevations (adjusted ORs 0.35 and 0.16, p = 0.045 and 0.022, respectively). Postoperative ischemia (>10 min), the more so prolonged (>30 min) ischemia was the only independent predictor of troponin elevation if added with the preoperative predictors to the multivariate analysis (ORs 15.8 and 22.8, respectively; p < 0.001).

CONCLUSIONS: Troponin elevations occur frequently after vascular surgery. They are strongly associated with postoperative ischemia, predicted by inducible ischemia on PTS, and reduced by preoperative coronary revascularization.

Abbreviations and Acronyms   CABG = coronary artery bypass graft surgery   CAD = coronary artery disease   CK-MB = creatine kinase-MB fraction   cTn = cardiac troponin   MI = myocardial infarction   OR = odds ratio   PCI = percutaneous coronary intervention   PTS = preoperative thallium scanning

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