Prognostic value of perioperative high sensitivity troponin in patients undergoing hip and knee arthroplasty

Souza, Fábio de; Barbato, Kelly Biancardini Gomes; Ferreira, Viviani Barreira Marangoni; Gualandro, Danielle Menosi; Caramelli, Bruno

doi:10.1016/j.clinsp.2024.100342

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Sumário

Original articles • Clinics 79 • 2024 • https://doi.org/10.1016/j.clinsp.2024.100342 copy

Prognostic value of perioperative high sensitivity troponin in patients undergoing hip and knee arthroplasty

Authorship SCIMAGO INSTITUTIONS RANKINGS

Highlights

To determine the prognostic value of perioperative hs-TnI in addition to traditional cardiac risk tools in patients undergoing elective major orthopedic surgery.

To evaluate the incidence of perioperative myocardial injury through systematic hs-TnI monitoring in a tertiary orthopedic center in Brazil.

Assessing mortality and cardiovascular complications in the short- and long-term periods after elective major orthopedic surgery.

Abstract

The authors conducted a prospective observational study to investigate the prognostic value of high-sensitivity Troponin I (hs-TnI) in the short- and long-term periods after orthopedic surgery, including Total Hip and Knee Arthroplasty (THA and TKA, respectively), in a tertiary orthopedic center in Brazil. Perioperative Myocardial Injury (PMI) was defined as an absolute increase in hs-TnI of ≥ 26 ng/L above preoperative values. The primary endpoint was all-cause mortality assessed at 30 days and 18 months after surgery. The secondary endpoint consisted of a composite outcome: cardiovascular death, acute myocardial infarction, angina requiring revascularization, and/or stroke. The authors compared Relative Risks (RR) of all-cause mortality and composite outcomes in patients with or without PMI at 30 days and 18 months. A Cox proportional hazards model for long-term outcomes was calculated and adjusted for age > 70 years, gender, and Revised Cardiac Risk Index (RCRI) class ≥ 2. PMI occurred in 3.4 % of all surgeries. At 30-days, 6.6 % of patients with PMI had died versus none without PMI. At 18 months, 20.0 % of PMI versus 4.7 % without PMI had died (RR = 5.0; 95 % Confidence Interval [95 % CI 1.3-19.3]). Based on composite outcomes in short and long-term periods, the RRs were 16.2 (95 % CI 2.7-96.5) and 7.7 (95 % CI 2.2-26.6), respectively. PMI was associated with all-cause mortality after 18 months and increased risk for a composite outcome (Hazard Ratio [HR = 3.97], 95 % CI 1.13-13.89 and HR = 5.80, 95 % CI 1.93-17.45, respectively). Patients with PMI who underwent THA or TKA presented worse short- and long-term prognoses compared to those without PMI.

Keywords
Perioperative period; Troponin; Orthopedics procedures; Mortality; Prognosis

Characteristics	All patients (n = 440)	Without hs-TnI variation (n = 425)	With hs-TnI variation (n = 15)
Gender, % female	56.4	56.0	66.7
Age, years	66.9 (9.3)	66.8 (9.3)	71.0 (7.3)
Age > 70 years, %	38.6	37.9	60.0
BMI, (kg/m²)	31.5 (5.9)	31.4 (5.7)	33.6 (9.1)
BMI > 30 kg/m², %	58.0	57.7	60.0
BMI > 40 kg/m², %	8.4	8.1	14.3
Comorbidities
Hypertension, %	78.6	78.4	86.7
Use of antihypertensive drugs, n	2 [0‒3]	2 [0‒3]	2 [1‒3]
Diabetes, %	23.0	23.3	13.3
Use of insulin, %	4.6	4.8	‒
Dyslipidemia, %	23.6	23.8	20.0
Current smoking, %	9.1	8.9	13.3
Coronary disease, %	6.8	6.4	20.0^b b p = 0.07.
Heart failure, %	6.1	6.1	6.7
Stroke, %	1.6	1.6	‒
Laboratory tests
Hemoglobin, mg/dL	12.8 [11.8‒13.6]	12.9 [11.8‒13.7]	12.4 [11.4‒14.2]
Fasting glucose, mg/dL	121 [106‒142]	121 [106‒142]	120 [107‒131]
Serum creatinine, mg/dL	1.1 [0.9‒1.3]	1.0 [0.9‒1.3]	1.1 [0.8‒1.3]
Serum creatinine > 2.0 mg/dL, %	2.1	2.1	‒
Risk classification
ASA, %
I	6.1	6.4	‒
II	75.0	75.5	60.0
III	18.9	18.1	40.0^b b p = 0.07.
RCRI (Lee), %
Class I	80.5	80.7	73.3
Class II	15.4	15.3	20.0
Class III	3.4	3.3	6.7
Class IV	0.7	0.7	‒
EMAPO, %
≤5 points	45.7	46.6	20.0
6 to 10 points	38.2	38.1	40.0
≥11 pontos	16.1	15.3	40.0^a a p = 0.02.

	30-days		18-months
	PMI (n = 15)	Without PMI (n = 425)	PMI (n = 15)	Without PMI (n = 425)
All-cause mortality	1 (6.6)	‒	3 (20.0)	20 (4.7)
Death for COVID-19^a a Deaths attributed to COVID-19 infection or occurring during the same hospitalization period in suspected cases.	‒	‒	‒	3 (0.7)
Composite Outcome ^b b Association of CV deaths and MACE (non-fatal stroke, AMI or angina requiring revascularization).	2 (13.3)	4 (0.9)	4 (26.6)	19 (4.5)
Cardiovacular death	1 (6.6)	‒	2 (13.3)	12 (2.8)
AMI/ angina	1(6.6)	‒	2 (13.3)	3 (0.7)
Stroke	‒	4 (0.9)	‒	4(0.9)

	HR 18-month all-cause mortality	p-value	HR 18-month composite outcome	p-value
PMI	3.97 [1.13-13.89]	0.031	5.80 [1.93-17.45]	0.002
Idade > 70 y	2.57 [1.09-6.02]	0.030	1.95 [0.84-4.53]	0.118
Sexo, male	2.83 [1.18-6.79]	0.019	2.55 [1.06-6.15]	0.036
RCRI class ≥ 2	1.35 [0.53-3.42]	0.521	2.56 [1.09-6.02]	0.031

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[1] * Corresponding author. E-mail address:bcaramel@usp.br (B. Caramelli)