Jean-Luc Fellahi | Hôpital Cardiologique et Pneumologique Louis Pradel, Hospices Civils de Lyon, Lyon, France
Note from the Editor: The second ESA Focus Meeting on Perioperative Medicine addressed all aspects of ‘The Cardiac Patient’ undergoing surgery. The faculty of international experts spoke to a full house of very satisfied and enthusiastic anaesthesiologists from around the world. Over 430 colleagues joined us in Nice from 50 countries, including the US, China, and several Middle Eastern countries – confirmation again of the ESA’s international high profile in scientific excellence. The full programme can be viewed on the website, ESA Members and meeting delegates can view the presentations by logging in. The 2016 Focus Meeting addresses The Ageing Patient, in Lisbon on 18-19 November. Save the date and make sure you’re there!
The session: How to Manage a Postoperative Increase in Troponin was chaired by Prof Fellahi.
With the widespread availability of troponin dosage at the bedside, numerous high-risk patients scheduled for noncardiac surgery exhibit a significant elevation in serum troponin within the postoperative period. That last point raises several questions of paramount importance for the attending practitioner, especially when patients are clinically asymptomatic. Two speakers with significant expertise in this area, Pr. Sylvain Ausset from Paris and Pr. Vincent Piriou from Lyon, tried to answer those questions in a dedicated session entitled ‘How to manage a postoperative increase in troponin?’.
Question 1: Is an asymptomatic troponin elevation clinically relevant?
Meta-analyses of small cohorts, post-hoc analysis of large cohorts, monocenter prospective studies, and a large multicenter prospective study (the VISION study) have clearly shown that even a slight increase in postoperative troponin was independently associated with a poor outcome on both short- and long-term bases, even in asymptomatic patients, and whatever the type of surgery. However, all troponin elevations are not equivalent and the mortality rate varies according to the existence of other demographic and/or clinical risk factors.
Question 2: What can we propose to those patients and how to manage them?
Published data to answer that crucial question are scarce in the literature. The single available study is a retrospective case-control study reporting that patients who experienced an increase in postoperative troponin and received an optimized medical treatment (a systematic association of an antiplatelet agent, a beta blocker, a statin, and an ACE inhibitor) following abdominal aortic surgery had a similar outcome to patients who did not experience an increase in postoperative troponin, and a better prognosis than patients with an increase in troponin who did not receive the optimized medical treatment. In contrast, another randomized trial found no difference in outcomes when high-risk patients with an elevated postoperative serum troponin were systematically admitted to the cardiologic intensive care unit. Many cohort studies also found that the imbalance in myocardial oxygen demand/supply within the postoperative period was associated with a higher incidence of increased troponin levels. Despite the lack of robust data regarding therapeutic options, the postoperative measurement of troponin permits, however, a 25% net reclassification improvement when compared to clinical risk scores alone, especially in intermediate to high-risk patients. Conversely, the measurement of postoperative troponin is probably useless in low-risk patients. Finally, given that postoperative myocardial infarction is most often a type 2 myocardial infarction related to prolonged myocardial oxygen imbalance rather than a type 1 myocardial infarction related to coronary artery occlusion (third universal classification of myocardial infarction), and knowing the negative results of the CARP study published ten years ago, the indications of preoperative surgical coronary revascularization are scarce nowadays. Targeting high-risk cardiac patients with cardiac frailty by using biological monitoring (serial postoperative troponin measurement) is the best way to select the patients who need to be addressed to the cardiologist at the time of hospital discharge.