Risk factors

Troponins identify surgery patients at high-risk of death

Elevated troponin levels in the first few hours and days after non-cardiac surgery can identify patients at an increased risk of dying, an international study involving thousands of patients shows.

The findings from the VISION trial of almost 22,000 surgical patients from 13 countries including Australia found patients with peak high-sensitivity troponin T (hs-TnT) between 20 and 64 ng/L had three-times the risk of death within 30 and a 3% absolute risk of 30-day mortality compared to patients with lower levels.

Patients with peak levels between ≥65 and <1000 ng/L had a 9.1% risk of dying within 30 days, while those with peak levels at or above 1000 ng/L had a 29.6% risk of 30-day mortality.

Speaking to the limbic, Professor Clara Chow, director of the George Institute’s cardiovascular division and a co-author of the paper, said it is difficult to diagnose an MI following surgery because the pain medications patients receive often mask chest pain.

“They are most likely still feeling pain from the surgery and sometimes they are sedated so it’s not necessarily that they’re completely asymptomatic but in the context of their surgery their symptoms may not be identified as cardiac.”

Dr Chow said a raised troponin can identify patients at risk of dying within the first 30 days after surgery but it was unclear what should be done with this information.

“Should we be routinely monitoring all these patients with troponin? That’s a fair bit of undertaking – but we’re identifying a high risk group here and that means we can do something about that risk.”

According to Professor Chow the people most at risk of having elevated hs-TnT levels are those with multiple cardiovascular risks, people with established cardiovascular or vascular disease, patients undergoing major operations and those who are older than 45.

“We are seeing increasingly higher risk and increasingly unwell patients undergoing surgery and I think that’s something we need to look at more broadly in Australia … how are we going to manage that situation because, in terms of the medical management, the models of care clearly aren’t there,” she told the limbic.

“There are no clear cut guidelines on how these patients should be managed however, I don’t think that means we shouldn’t test troponin levels – I think we would probably rather know who’s at higher risk and then look after them as best we can.”

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