The other main controversy in his view is the ACC/AHA stance on postoperative troponin measurement. It gets a class III rating – meaning no benefit, don’t do it – for routine screening in unselected patients without signs or symptoms suggestive of myocardial ischemia. This recommendation is based upon the absence to date of a prospective trial showing that acting on an elevated postoperative troponin in such patients improves outcomes. True enough, Dr. Burke conceded, but he finds persuasive the results of VISION (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation), a prospective international study in which more than 15,000 patients undergoing noncardiac surgery underwent screening troponin measurements on the first 3 days after surgery.
Thirty-day mortality in the VISION study was 1% in those with a peak fourth-generation troponin of 0.01 ng/mL or less. Mortality was significantly increased in the nearly 12% of patients with a troponin of at least 0.02 ng/mL, climbing to a peak mortality rate of 16.9% in those with a postoperative troponin of 0.30 ng/mL or more (JAMA. 2012 Jun 6;307[21]:2295-304).
“I don’t know of any other test in the perioperative setting that’s as good as this in terms of risk-stratifying patients. We can’t just sit by and let this sort of 30-day mortality rate happen. We should do something. I think that if you treat these asymptomatic patients with an elevated postop troponin as if they had an MI – get them on optimal medical therapy and really push smoking cessation – it’s likely to have a benefit on outcomes,” said Dr. Burke.
He reported having no financial conflicts regarding his presentation.