Postoperative Troponin Screening
A Cardiac Cassandra?
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The cardiovascular management of the patient undergoing noncardiac surgery has been in evolution for the last 35 years. Over this time frame, 2 secular trends have advanced in parallel but provided contrary practice implications for the care of the surgical patient. First, cardiovascular event rates have been dropping significantly over time. In 1977, Goldman et al1 created a risk evaluation system that predicted a 22% rate of life-threatening cardiovascular events and >50% mortality in the highest-risk group in 1001 patients undergoing surgery. These rates of events have dropped significantly each decade since. Finks et al2 reported 2 years ago a mere 2.8% national mortality rate for open abdominal aortic aneurysm repair, the exemplar of routine, high-risk surgery. These numbers were recapitulated worldwide for high-risk patients undergoing noncardiac surgery in the Perioperative Ischemic Evaluation (POISE) trial.3 Improvements in surgical and anesthetic techniques, perioperative medical therapy, and intensive care have contributed to the significant improvement in outcomes.
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Second, the sensitivity of testing to detect evidence of cardiovascular disease or ischemia has increased dramatically. In this same time frame, risk assessment has evolved from stress testing to nuclear-vasodilator testing, inotropic echocardiographic assessment, cardiac magnetic resonance imaging, and positron emission tomographic scanning. Counterintuitively, the ability to accurately detect smaller and smaller amounts of disease has not improved postoperative cardiovascular event prognostication. Indeed, the positive predictive value for each of these modalities in predicting a cardiovascular event remains <20%.4 The poor performance may be attributed to 2 components. First, improvements in disease detection foster inclusion of patients previously deemed healthy by less sensitive modalities. Indeed, it is the specific coronary heart disease detection improvement that undermines its prognostic value in the stable patient by diminishing the risk of the group with a positive study. Second, ever-dropping event …