HSS Journal

, Volume 4, Issue 1, pp 76–80 | Cite as

The One Year Incidence of Postoperative Myocardial Infarction in an Orthopedic Population

  • M. K. UrbanEmail author
  • K. Jules-Elysee
  • C. Loughlin
  • W. Kelsey
  • E. Flynn
Original Article


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.

Key words

postoperative myocardial infarction troponin levels 


  1. 1.
    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 17:843–850PubMedCrossRefGoogle Scholar
  2. 2.
    Graeber GM (1985) Creatine kinase (CK): its use in the evaluation of perioperative myocardial infarction. Surg Clin North Am 65:539–551PubMedGoogle Scholar
  3. 3.
    Mangano DT (1990) Perioperative cardiac morbidity. Anesthesiology 72:153–184PubMedCrossRefGoogle Scholar
  4. 4.
    Adams JE, Bodor GS, Davila-Roman VG et al (1993) Cardiac troponin I: a marker with high specificity for cardiac injury. Circulation 88:101–106PubMedGoogle Scholar
  5. 5.
    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 13:556–560PubMedCrossRefGoogle Scholar
  6. 6.
    Knight AA, Hollenberg M, London MJ et al (1988) Perioperative myocardial ischemia: importance of the preoperative ischemic pattern. Anesthesiology 68:681–688PubMedCrossRefGoogle Scholar
  7. 7.
    Adams JE, Sigard GA, Allen BT (1994) Diagnosis of perioperative myocardial infarction with measurement of cardiac Troponin I. N Engl J Med 330:670–674PubMedCrossRefGoogle Scholar
  8. 8.
    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 55:641–647CrossRefGoogle Scholar
  9. 9.
    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 43:2047–2051PubMedGoogle Scholar
  10. 10.
    The Joint European Society of Cardiology/American College of Cardiology Committee (2000) Myocardial infarction redefined. J Am Coll Cardiol 36:959–969CrossRefGoogle Scholar
  11. 11.
    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 90:1257–1261PubMedCrossRefGoogle Scholar
  12. 12.
    Kim LJ, Martinez A, Faraday N et al (2002) Cardiac Troponin I predicts short-term mortality in vascular surgical patients. Circulation 106:2366–2371PubMedCrossRefGoogle Scholar
  13. 13.
    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 59:318–323CrossRefGoogle Scholar
  14. 14.
    Manach YL, Perel A, Coriat P et al (2005) Early and delayed myocardial infarction after abdominal aortic surgery. Anesthesiology 102:885–891PubMedCrossRefGoogle Scholar
  15. 15.
    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 96:1140–1146PubMedCrossRefGoogle Scholar
  16. 16.
    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 19:577–582PubMedCrossRefGoogle Scholar
  17. 17.
    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 18:280–285PubMedCrossRefGoogle Scholar
  18. 18.
    Edouard AR, Felten ML, Herbert JL (2004) Incidence and significance of cardiac troponin I release in severe in severe trauma patients. Anesthesiology 101:1262–1268PubMedCrossRefGoogle Scholar
  19. 19.
    Urban MK, Urquhart B (1993) Is controlled hypotensive anesthesia safe for elderly patients undergoing total hip arthroplasty. Anesthesiology A167Google Scholar
  20. 20.
    Urban MK, Sheppard R, Gordon MA et al (1996) Right ventricular function during revision total hip arthroplasty. Anesth Analg 82:1225–1229PubMedCrossRefGoogle Scholar
  21. 21.
    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 5:592–597CrossRefGoogle Scholar
  22. 22.
    LeManach YL, Perel A, Coriat P et al (2005) Early and delayed myocardial infarction after abdominal aortic surgery. Anesthesiology 102:885–891CrossRefGoogle Scholar
  23. 23.
    Agewall S, Lowbeer C (2005) The new definition of myocardial infarction—Can we use it? Clin Cardiol 28:77–80PubMedCrossRefGoogle Scholar

Copyright information

© Hospital for Special Surgery 2007

Authors and Affiliations

  • M. K. Urban
    • 1
    Email author
  • K. Jules-Elysee
    • 1
  • C. Loughlin
    • 1
  • W. Kelsey
    • 1
  • E. Flynn
    • 1
  1. 1.Department of AnesthesiologyHospital for Special SurgeryNew YorkUSA

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