Surgery
Usefulness of cardiac troponin I in patients undergoing open heart surgery

https://doi.org/10.1067/mhj.2001.113071Get rights and content

Abstract

Background Significant myocardial injury during cardiac surgery is associated with a 10-fold increase in 2-year complication rates, yet there remains no clinical gold standard for diagnosis. Troponin I has complete cardiospecificity and is clinically used for diagnosis of myocardial infarction in other settings. Methods and Results One hundred consecutive patients undergoing open heart surgery (71 coronary artery bypass grafts and 29 aortic valve replacements) were enrolled and blood samples were drawn preoperatively, at 5 AM and 5 PM on days 1 and 2 after surgery, and at 5 AM for 3 more days. Twelve-lead electrocardiograms were performed daily and echocardiographic studies were performed on patients with either; electrocardiographic changes signifying likely myocardial damage, intraoperative complications, or elevated creatine kinase subfraction MB or troponin values. Seventeen patients had either new wall motion abnormalities or new Q waves all with peak cardiac troponin I >40 ng/mL. Stratification of patients by peak troponin values <40 and >60 ng/mL was highly predictive (P <.001) of days in intensive care unit, days on ventilator, development of new arrhythmia, and especially cardiac events. These postoperative variables also showed a stronger correlation with peak cardiac troponin I than did peak creatine kinase subfraction MB. Conclusion Peak troponin I values detect myocardial infarction the day after heart surgery and predicts patient outcome. (Am Heart J 2001;141:447-55.)

Section snippets

Patients

During the 10-month period (5/98 to 3/99) we prospectively evaluated 100 consecutive patients referred to the San Diego Veterans Affairs Health Care System for open heart surgery and who agreed to participate in the study. Approval of consent was obtained by the University of California, San Diego, Committee on Human Subjects.

Study protocol

Blood samples (2-3 mL) were obtained from patients preoperatively and at 5 AM and 5 PM for the first 2 days after surgery. After this, blood was sampled each morning for 1

Results

Preoperative, operative, and clinical end point data are presented in Table I.

. Preoperative, operative, and clinical end point data

Patient data (mean ± SEM)
 Total No. of patients100
 Preoperative ejection fraction (%)47 ± 1.5
 No. of patients with myocardial infarction <6 wk10
 Age (y)66 ± 1.1
 Average No. of vessel disease1.8 ±.3
 No. of patients with hypertension75
 No. of patients with non-insulin-dependent diabetes mellitus31
 No. of patients with insulin-dependent diabetes mellitus8
 No. of patients with

Discussion

Outcome-based medicine is becoming the accepted standard of care of patients treated for specific illnesses in our society. In the case of cardiac surgery, however, there remain few adverse measurable end points other than 30-day mortality. Although perioperative myocardial injury after cardiac surgery is an accepted clinical outcome responsible for a severalfold increase in morbidity and mortality,12, 13 there is currently no effective clinical gold standard for its detection. The ability to

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      The post hoc power analysis revealed 98% power for the detected difference. Previous clinical studies found that peripheral blood levels of the myocardial necrosis marker cTnI increased after open heart surgery and correlated with the length of time of AXCL and CPB [27,28]. We confirmed that in our patients undergoing open heart surgery, cTnI levels increased significantly following surgery (P < 0.001, paired t-test comparing cTnI levels in each post-surgery time points with that of the pre-surgery time point) (Fig. 3).

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    Reprint requests: Alan Maisel, MD, VAMC Cardiology, 3350 La Jolla Village Dr, San Diego, CA 92161. E-mail: [email protected]

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