• Writing Committee for the VISION Study Investigators, P J Devereaux, Bruce M Biccard, Alben Sigamani, Denis Xavier, ChanMatthew T VMTVChinese University of Hong Kong, Hong Kong Special Administrative Region, China., Sadeesh K Srinathan, Michael Walsh, Valsa Abraham, Rupert Pearse, C Y Wang, Daniel I Sessler, Andrea Kurz, Wojciech Szczeklik, Otavio Berwanger, Juan Carlos Villar, German Malaga, Amit X Garg, Clara K Chow, Gareth Ackland, Ameen Patel, Flavia Kessler Borges, Emilie P Belley-Cote, Emmanuelle Duceppe, Jessica Spence, Vikas Tandon, Colin Williams, Robert J Sapsford, Carisi A Polanczyk, Maria Tiboni, Pablo Alonso-Coello, Atiya Faruqui, Diane Heels-Ansdell, Andre Lamy, Richard Whitlock, Yannick LeManach, Pavel S Roshanov, Michael McGillion, Peter Kavsak, Matthew J McQueen, Lehana Thabane, Reitze N Rodseth, BuseGiovanna A LuratiGALUniversity Hospital Düsseldorf, Düsseldorf, Germany., Mohit Bhandari, Ignacia Garutti, Michael J Jacka, Holger J Schünemann, Olga Lucía Cortes, Pierre Coriat, Nazari Dvirnik, Fernando Botto, Shirley Pettit, Allan S Jaffe, and Gordon H Guyatt.
• McMaster University, Hamilton, Ontario, Canada.
• JAMA. 2017 Apr 25; 317 (16): 1642-1651.

ImportanceLittle is known about the relationship between perioperative high-sensitivity troponin T (hsTnT) measurements and 30-day mortality and myocardial injury after noncardiac surgery (MINS).ObjectiveTo determine the association between perioperative hsTnT measurements and 30-day mortality and potential diagnostic criteria for MINS (ie, myocardial injury due to ischemia associated with 30-day mortality).Design, Setting, And ParticipantsProspective cohort study of patients aged 45 years or older who underwent inpatient noncardiac surgery and had a postoperative hsTnT measurement. Starting in October 2008, participants were recruited at 23 centers in 13 countries; follow-up finished in December 2013.ExposuresPatients had hsTnT measurements 6 to 12 hours after surgery and daily for 3 days; 40.4% had a preoperative hsTnT measurement.Main Outcomes And MeasuresA modified Mazumdar approach (an iterative process) was used to determine if there were hsTnT thresholds associated with risk of death and had an adjusted hazard ratio (HR) of 3.0 or higher and a risk of 30-day mortality of 3% or higher. To determine potential diagnostic criteria for MINS, regression analyses ascertained if postoperative hsTnT elevations required an ischemic feature (eg, ischemic symptom or electrocardiography finding) to be associated with 30-day mortality.ResultsAmong 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom.Conclusions And RelevanceAmong patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.

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