Abstract
The diagnosis of a postoperative myocardial infarction (PMI) is important in the orthopedic population because these events can be associated with significant cardiac morbidity. Plasma troponin I (cTnI) analysis has markedly increased our ability to detect myocardial damage. Using cTnI analysis for evidence of a PMI, we prospectively assessed all of our patients for (1) the 1-year incidence of PMI, (2) the clinical consequences of a PMI in relation to the level of the cTnI release, and (3) 6-month follow-up for cardiac complications. During a 12-month period, patients at risk for perioperative myocardial ischemia were assessed for a PMI by serum cTnI levels and daily serial ECGs. Patients with cTnI levels above the reference level (≥0.4 ng/ml) were also assessed for new cardiac regional wall motion abnormalities with an echocardiogram and 6-month postdischarge adverse cardiac events. Of the 758 patients who were assessed for a PMI, 49 patients had detectable cTnI levels (≥0.4 ng/ml); the incidence of a PMI was 0.6% of all surgical cases and 6.5% of those patients were at risk for a cardiac event. A PMI was more common after hip arthroplasty than other orthopedic procedures. Twenty-three patients had a cTnI level >3.0 ng/ml, and 74% these patients (17/23) had anginal symptoms and/or ischemic ECG changes. Nine of these patients (9/23) had new postoperative echocardiographic changes, five (5/23) required emergency transfer to a cardiac care unit, and 10 (10/23) had postoperative cardiac complications. In contrast, 15 patients with levels of cTnI <3.0 ng/ml and without ischemic ECG changes and/or anginal symptoms had no postoperative cardiac complications. Fourteen patients (14/47) had cardiac complications 6 months after discharge, including four cardiac deaths, one fatal stroke, and four patients with unstable anginal episodes that required a change in medical management, and six patients required coronary revascularization. Orthopedic surgical patients with cTnI level <3 ng/ml and without symptoms or ECG changes suggestive of myocardial ischemia (15/49) may have different risks than those with higher-level cTn1.
Similar content being viewed by others
References
Mangano DT, Hollenberg M, Fegert G et al (1991) Perioperative myocardial ischemia in patients undergoing noncardiac surgery-I. Incidence and severity during the 4 day perioperative period. J Am Coll Cardiol 17:843–850
Graeber GM (1985) Creatine kinase (CK): its use in the evaluation of perioperative myocardial infarction. Surg Clin North Am 65:539–551
Mangano DT (1990) Perioperative cardiac morbidity. Anesthesiology 72:153–184
Adams JE, Bodor GS, Davila-Roman VG et al (1993) Cardiac troponin I: a marker with high specificity for cardiac injury. Circulation 88:101–106
Jules-Elysee K, Urban MK, Urquhart B et al (2001) Troponin as a diagnostic marker of a perioperative myocardial infarction in the orthopedic population. J Clin Anesth 13:556–560
Knight AA, Hollenberg M, London MJ et al (1988) Perioperative myocardial ischemia: importance of the preoperative ischemic pattern. Anesthesiology 68:681–688
Adams JE, Sigard GA, Allen BT (1994) Diagnosis of perioperative myocardial infarction with measurement of cardiac Troponin I. N Engl J Med 330:670–674
Neil F, Sear JW, French G et al (2000) Increases in serum concentrations of cardiac proteins and the prediction of early postoperative cardiovascular complications in noncardiac surgery patients. Anaesthesia 55:641–647
Apple FS, Falahati A, Paulsen PR et al (1997) Improved detection of minor ischemic myocardial injury with measurement of serum cardiac troponin I. Clin Chem 43:2047–2051
The Joint European Society of Cardiology/American College of Cardiology Committee (2000) Myocardial infarction redefined. J Am Coll Cardiol 36:959–969
Urban MK, Markowitz SM, Gordon MA et al (2000) Postoperative prophylactic administration of β-adrenergic blockers in patients at risk for myocardial ischemia. Anesth Analg 90:1257–1261
Kim LJ, Martinez A, Faraday N et al (2002) Cardiac Troponin I predicts short-term mortality in vascular surgical patients. Circulation 106:2366–2371
Hingham H, Sear JW, Sear YM et al (2004) Peri-operative troponin I concentration as a marker of long-term postoperative adverse cardiac outcomes—A study in high risk surgical patients. Anaesthesia 59:318–323
Manach YL, Perel A, Coriat P et al (2005) Early and delayed myocardial infarction after abdominal aortic surgery. Anesthesiology 102:885–891
Mantilla CB, Horlocker TT, Schroeder DR et al (2002) Frequency of myocardial infarction, pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty. Anesthesiology 96:1140–1146
Martinez EA, Nass CM, Jermyn RM et al (2005) Intermittent cardiac troponin-I screening is an effective means of surveillance for a perioperative myocardial infarction. J Cardiothorac Vasc Anesth 19:577–582
Barbagallo M, Casati A, Spadini E et al (2006) Early increases in cardiac troponin levels after major vascular surgery is associated with an increased frequency of delayed cardiac complications. J Clin Anesth 18:280–285
Edouard AR, Felten ML, Herbert JL (2004) Incidence and significance of cardiac troponin I release in severe in severe trauma patients. Anesthesiology 101:1262–1268
Urban MK, Urquhart B (1993) Is controlled hypotensive anesthesia safe for elderly patients undergoing total hip arthroplasty. Anesthesiology A167
Urban MK, Sheppard R, Gordon MA et al (1996) Right ventricular function during revision total hip arthroplasty. Anesth Analg 82:1225–1229
Godet G, Dumerat M, Baillard C et al (2000) Cardiac troponin I is a reliable marker for immediate but not medium-term cardiac complications after abdominal aortic repair. Acta Anaesthesiol Scand 5:592–597
LeManach YL, Perel A, Coriat P et al (2005) Early and delayed myocardial infarction after abdominal aortic surgery. Anesthesiology 102:885–891
Agewall S, Lowbeer C (2005) The new definition of myocardial infarction—Can we use it? Clin Cardiol 28:77–80
Author information
Authors and Affiliations
Corresponding author
Additional information
This study was funded by the Department of Anesthesiology, Hospital for Special Surgery, New York, NY.
Rights and permissions
About this article
Cite this article
Urban, M.K., Jules-Elysee, K., Loughlin, C. et al. The One Year Incidence of Postoperative Myocardial Infarction in an Orthopedic Population. HSS Jrnl 4, 76–80 (2008). https://doi.org/10.1007/s11420-007-9070-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11420-007-9070-3