title: Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes.
abstract: BACKGROUND
  Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study's four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS.
  
  
  METHODS
  In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated "abnormal" laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria.
  
  
  RESULTS
  An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors' diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96-5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6-41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom.
  
  
  CONCLUSIONS
  Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.
authors.affiliation: From the Hamilton General Hospital, David Braley Cardiac, Vascular, and Stroke Research Institute, Population Health Research Institute, Hamilton, Ontario, Canada (P.J.D.); and Members of The VISION Writing Group and VISION Investigators, who are listed in appendix 1 and appendix 2, respectively. Population Health Research Institute, Hamilton, Ontario, Canada; Department of Clinical Research, Estudios Clinicos Latino America (ECLA), Rosario, Argentina Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain The Chinese University of Hong Kong, Shatin, N.T., Hong Kong Universidad Autónoma de Bucaramanga and Fundación Cardioinfantil, Colombia St. John's Medical College and Research Institute, Bangalore, India Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada Department of Clinical Epidemiology and Biostatistics and Department of Medicine, McMaster University, Hamilton, Ontario, Canada Hospital General Universitario Gregorio Maranon, Madrid, Spain University of Alberta, Edmonton, Alberta, Canada University of Malaya, Kuala Lampur, Malaysia Research Institute Hcor (Hospital do Coracao), Sao Paulo, Brazil Barts & The London School of Medicine and Dentistry, London, United Kingdom University of Kwazulu-Natal, Durban, South Africa Christian Medical College, Ludhiana, India Universidad PeruanaCayetano Heredia, Lima, Peru The George Institute for Global Health, University of Sydney, Sydney, Australia Population Health Research Institute, Hamilton, Ontario, Canada; University of Kwazulu-Natal, Durban, South Africa Department of Clinical Epidemiology and Biostatistics, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada Hospital de Clinicas de Porto Alegre, Universidade Federal de Rio Grande do Sul, Brazil Jagiellonian University Medical College, Krakow, Poland The Cleveland Clinic, Cleveland, Ohio Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilto
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authors.forename: Pervez
authors.initials: P
authors.lastname: Sultan
authors.forename: David
authors.initials: D
authors.lastname: Cain
authors.forename: John
authors.initials: J
authors.lastname: Whittle
authors.forename: Ana Gutierrez
authors.initials: AG
authors.lastname: Del Arroyo
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.forename: Andrea
authors.initials: A
authors.lastname: Kurz
authors.forename: Zhuo
authors.initials: Z
authors.lastname: Sun
authors.forename: Patrick S
authors.initials: PS
authors.lastname: Finnegan
authors.forename: Cameron
authors.initials: C
authors.lastname: Egan
authors.forename: Hooman
authors.initials: H
authors.lastname: Honar
authors.forename: Aram
authors.initials: A
authors.lastname: Shahinyan
authors.forename: Krit
authors.initials: K
authors.lastname: Panjasawatwong
authors.forename: Alexander Y
authors.initials: AY
authors.lastname: Fu
authors.forename: Sihe
authors.initials: S
authors.lastname: Wang
authors.forename: Edmunds
authors.initials: E
authors.lastname: Reineks
authors.forename: Peter
authors.initials: P
authors.lastname: Nagele
authors.forename: Jane
authors.initials: J
authors.lastname: Blood
authors.forename: Megan
authors.initials: M
authors.lastname: Kalin
authors.forename: David
authors.initials: D
authors.lastname: Gibson
authors.forename: Troy
authors.initials: T
authors.lastname: Wildes
mesh_terms: D017677:Age Distribution; D000368:Aged; D015331:Cohort Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000097:blood / Q000175:diagnosis* / Q000453:epidemiology*; D063868:Patient Outcome Assessment; D011183:Postoperative Complications / Q000097:blood / Q000175:diagnosis* / Q000453:epidemiology*; D011379:Prognosis; D011446:Prospective Studies; D013514:Surgical Procedures, Operative; D020107:Troponin T / Q000097:blood
chemical_list: D020107:Troponin T