Effect of a national guideline on postoperative troponin surveillance: A retrospective cohort study in a single institution in Canada

• Published in: Journal of cardiothoracic and vascular anesthesia 2023-10, Vol.37, p.20-21
• Main Authors: TORRES, Eva Alvarez, BARTOSZKO, Justyna, PÉREZ, Selene Martínez, TAIT, Gordon, SANTEMA, Michael, BEATTIE, William Scott, MCCLUSKEY, Stuart, VAN KLEI, Wilton
• Format: Article
• Language: English
• ISSN: 1053-0770
• DOI: 10.1053/j.jvca.2023.08.056

Myocardial Infarction (MI) is a rare but potentially fatal complication after non-cardiac surgery (1-2). Strategies to detect myocardial ischemia by troponin surveillance have been recommended (3-4). The 2017 Canadian Cardiovascular Society (CCS) guideline on perioperative cardiac risk assessment recommends measuring Brain Natriuretic Peptide (BNP) or N-terminal pro-BNP (NT-proBNP) preoperatively in patients 65 years or older, or 45-64 years old with significant cardiovascular disease (CVD), or who have at least one Revised Cardiac Risk Index factor. Postoperative troponin surveillance is recommended when BNP or NT-proBNP is elevated, or in all these patients when these results are not available (4). We aimed to evaluate the effect of the 2017 CCS guideline on troponin surveillance and outcomes after non-cardiac surgery. After approval from the institutional Research Ethics Board we conducted a single center (UHN) retrospective observational study. Patients aged 40 years or older undergoing intermediate- to high-risk elective non-cardiac surgery between 2016 and 2021 were included. We first compared the number and percentage of troponin tests ordered before and after the guideline was published and compared patient characteristics, specifically cardiovascular comorbidity, using Odds Ratio's (OR) with 95% Confidence Intervals (CI). Second, the occurrence of myocardial injury, MI, and in-hospital mortality before and after guideline publication were compared. The cohort included 36,386 patients. Median age was 63 years. According to the guideline, troponin surveillance was recommended in 20,807 (57%) patients, was actually ordered in 4,859 (13%) and elevated in 1,031 (2.8%). Between 2016-2018 troponin surveillance was done in 2,461 (13%) of the 19,046 patients, compared to 2,398 (14%) of the 17,340 patients who had surgery between 2019-2021 (OR 1.1, 95% CI: 1.0-1.2). Patients undergoing surgery in the second period had less CVD. Adding troponin surveillance according to the guideline to a regression model predicting MI did not have added value. Adding actual troponin ordering, however, was significantly associated with MI (OR 19, 95% CI: 11-34) and mortality (OR 5.7, 95% CI: 4.1-7.8). Publication of the CCS guidelines did not impact the number of troponin tests ordered. Surveillance according to the CCS guideline would have resulted in monitoring more than half of the population, without a significant increase in outcome detection rates. In conclusion, the C