Editorial
Analytic comments of the initial results of the VISION (Vascular events In noncardiac Surgery patIents cOhort evaluatioN): Association between troponin T and mortality at 30 days in noncardiac surgery patients
Comentarios analíticos del estudio VISION (evaluación de cohorte de eventos vasculares en pacientes de cirugía no cardiaca): asociación entre la troponina T y la mortalidad a los 30 días en pacientes de cirugía no cardiaca
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Garutti, P. Paniagua, P. Cruz, M.L. Maestre, C. Fernández-Riveira, P. Alonso-Coello" "autores" => array:7 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Garutti" "email" => array:1 [ 0 => "ngaruttimartinez@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Paniagua" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "Cruz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "M.L." 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"apellidos" => "Alonso-Coello" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 6 => array:2 [ "colaborador" => "for the Spanish VISION Investigators" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">◊</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Sant Pau, Barcelona, Spain" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centro Cochrane Iberoamericano, Instituto de Investigación Biomédica (IIB-Sant Pau), Barcelona, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comentarios analíticos del estudio VISION <span class="elsevierStyleItalic">(evaluación de cohorte de eventos vasculares en pacientes de cirugía no cardiaca)</span>: asociación entre la troponina T y la mortalidad a los 30 días en pacientes de cirugía no cardiaca" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1641 "Ancho" => 2406 "Tamanyo" => 198642 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient management in the VISION study.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The initial results of the VISION study (<span class="elsevierStyleUnderline">V</span>ascular events <span class="elsevierStyleUnderline">I</span>n noncardiac <span class="elsevierStyleUnderline">S</span>urgery pat<span class="elsevierStyleUnderline">I</span>ents c<span class="elsevierStyleUnderline">O</span>hort evaluatio<span class="elsevierStyleUnderline">N</span>) have recently been published in JAMA.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> VISION was proposed, designed, and directed by the team of Dr. Devereaux (McMaster University, Ontario, Canada), a cardiologist–epidemiologist who runs a perioperative ischemia research program.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> VISION is a prospective international multicenter cohort study, with more than 20,000 patients recruited to date. The two participating centers in Spain, with over 3700 patients included, are, respectively, Hospital Sant Pau in Barcelona, and Hospital Gregorio Marañón, in Madrid. The study initially intended to recruit 40,000 patients; however, due to a change in the type of troponin T (TnT) assay being used in many hospitals – the fourth-generation TnT assay has been progressively replaced by the ultrasensitive fifth-generation TnT assay – only fourth-generation troponin T results have been analyzed. VISION is currently ongoing in hospitals of the other countries, although monitoring is now being conducted with the fifth-generation TnT assay.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The VISION design is relatively simple and pragmatic. TnT is monitored in all consecutive patients with 45 years of age or more who undergo noncardiac surgery (scheduled or urgent/emergent) and stay in hospital for at least one night after surgery. In patients who give their consent, TnT is measured four times at 6–12<span class="elsevierStyleHsp" style=""></span>h on days 1, 2, and 3 after surgery. Patients with TnT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>0.04<span class="elsevierStyleHsp" style=""></span>ng/mL (that is considered the threshold value) in any of the samples are managed as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The main objectives of this study were: (1) analyzing the association between postoperative TnT values and postoperative mortality; (2) analyzing the incidence of major vascular events after surgery (death from vascular cause, nonfatal acute myocardial infarction – AMI-, cardiac arrest, and syncope); (3) developing an optimal clinical model for predicting major vascular complications after surgery; and (4) assessing the proportion of patients who experience an AMI at 30 days after surgery which would not have been detected without the monitoring with TnT. Results corresponding to the first objective have now been published with the peak TnT value during the first 3 days after surgery being significantly associated with mortality at 30 days.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This first analysis included 15,133 patients and adopted a risk model in which the dependent variable was death at 30 days, the incidence being 1.9% (282/15,133). The model included 24 preoperative variables, of which only 11 were independent risk factors for death at 30 days (age, recent high-risk coronary disease, peripheral vascular disease, stroke, chronic obstructive pulmonary disease, active cancer, urgent or emergency surgery, major general surgery, major neurosurgery, heart failure history, and major vascular surgery). The variable with the greatest risk was emergency surgery (rate ratio or adjusted hazard ratio 4.62 [95% CI, 3.57–5.98]). A second risk model was conducted, using the same variables as the first one, but this time including the variable “peak TnT during the first 72<span class="elsevierStyleHsp" style=""></span>h”. Results showed that this was associated with the greatest risk of death at 30 days.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with a peak TnT value of 0.01 or less, 0.02, 0.03–0.29, and 0.30<span class="elsevierStyleHsp" style=""></span>ng/mL or greater had 30-day mortality rates of 1.0%, 4.0%, 9.3%, and 16.9%, respectively. Peak TnT measurement added incremental prognostic value to discriminate those likely to die within 30 days for the model with peak TnT measurement vs those without. The population-attributable risk suggests that patients showing increased TnT levels suffered 41.8% of deaths during the first 30 days after surgery. During the first 3 days after noncardiac surgery, 1 in 25 patients with a fourth-generation TnT value of 0.02<span class="elsevierStyleHsp" style=""></span>ng/mL would die within a month, as would 1 in 11 with TnT ranging from 0.03<span class="elsevierStyleHsp" style=""></span>ng/mL to 0.29 and 1 in 6 with TnT greater than 0.3<span class="elsevierStyleHsp" style=""></span>ng/mL.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Perioperative cardiovascular complications are an important concern among clinicians responsible for patients’ perioperative care. The only prospective study to date aimed at determining cardiovascular risk in surgery in nonselected patients is that conducted by Lee et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Based on their findings, the authors developed the Lee risk index, which is widely used in clinical practice. However, this study was based on 4315 patients recruited from 1989 to 1994, excluded patients undergoing emergency surgery, did not consider syncope as a vascular complication, and used CPK-MB as a biomarker of myocardial damage. These limitations make it, therefore, necessary to establish new risk indexes representative of current perioperative care. The VISION study will deal with this issue in the near future with the development of a risk prediction model that addresses the limitations of the previous ones.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Perioperative myocardial infarctions (PMIs) differ considerably from those observed in nonsurgical patients, and they often go undetected unless cardiac enzymes or troponins are monitored after surgery. A joint analysis of studies investigating this finding showed that only 16% of patients with PMI have the characteristic chest pain/tightness.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> The reasons for this are: (1) most cases of AMI occur during the first 3 days after surgery, when patients usually receive analgesics; (2) a small number of patients (generally with high cardiac risk) remain intubated or sedated during this period of greatest risk; (3) postoperative signs (hypotension, tachycardia) and symptoms (dyspnea, nausea) generally experienced by patients after the surgical procedure that in other circumstances would alert us of a MI are usually attributed to other postoperative complications (e.g. pneumonia, atelectasis, hypovolemia, bleeding, incisional pain or medication side effects). Thus in this context, specific biomarkers such as TnT become very relevant. To date most studies have evaluated the performance of CPK-MB for the diagnosis of perioperative MI. However, compared with TnT, CPK, being a striated muscle enzyme, yields a high proportion of false positives.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Furthermore, during the first few days after surgery, CPK levels are high as a result of postsurgical trauma; therefore, the CPK-MB/CPK ratio is usually low, leading to false negatives too. The prognostic value of TnT has been analyzed in a meta-analysis of 14 studies (3318 patients and 459 deaths) by Devereaux's research group showing the usefulness of monitoring TnT for predicting postoperative mortality during the first year (data on CPK-MB were limited).<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">However, no studies to date have investigated the performance of TnT monitoring in a large of nonselected cohort of surgical patients such as those included in the VISION study. Even though TnT is not routinely measured after noncardiac surgery, the simplicity of the test and its performance suggest that it could prove being considerably useful in the immediate postoperative period. However, the type of patient and/or surgery in which the cost-effectiveness ratio would advise routine monitoring of TnT has yet to be determined. The cost-effectiveness of TnT monitoring will be addressed in the near future in the VISION study.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A key finding from this first VISION analysis is that TnT numbers that are considered irrelevant in clinical practice have shown a poorer prognostic value than what was previously thought. In <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> we can see that cardiologist was only called when TnT was >0.04<span class="elsevierStyleHsp" style=""></span>ng/mL. However patients with TnT between 0.02 and 0.04<span class="elsevierStyleHsp" style=""></span>ng/mL had a fourfold higher risk of death than patients with values lower than 0.01<span class="elsevierStyleHsp" style=""></span>ng/mL (4% vs 1%). The findings of VISION must therefore change clinical practice.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Another striking aspect of the initial results of VISION is the association between peak TnT values and mortality due to nonvascular complications. Nonvascular mortality was almost twice that of vascular mortality among patients with a peak TnT value between 0.02 and 0.029<span class="elsevierStyleHsp" style=""></span>ng/mL (1.41% vs 2.63%); nevertheless, in patients with higher TnT values this difference was not observed. This finding could be based on the assumption that patients with myocardial damage might be expected to have a higher risk of a noncardiologic complication and/or that silent myocardial insult could mean that any nonvascular complication would imply a poorer prognosis (e.g. a patient with pneumonia would be less able to overcome the increased myocardial demand for oxygen). In other words, by reducing the degree of postoperative silent myocardial damage, we would be improving both the prognosis of vascular complications, and of nonvascular complications.</p><p id="par0055" class="elsevierStylePara elsevierViewall">As with nonsurgical patients, early diagnosis of postoperative myocardial ischemia makes it possible to apply more effective measures for preventing death (monitoring in critical care units, coronary procedures, and more rigorous correction of hypovolemia, hypoxia, and anemia). In addition, many patients with high postoperative TnT levels do not receive prophylaxis (aspirin, betablocking drugs, statins, angiotensin-converting enzyme inhibitors), and treatment could be administered as soon as this peak is detected. However, the optimal approach to managing postoperative myocardial damage is still to be determined in order to improve prognosis. Moreover, adequately powered clinical trials are necessary.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Finally, it seems clear that a standard diagnostic strategy is insufficient to detect PMIs and that biochemical tests are needed in the noncardiac surgical population.</p><p id="par0060" class="elsevierStylePara elsevierViewall">As the results of VISION are being analyzed, the available data on other aspects of perioperative cardiac-related risk will represent an important advance for all those working in perioperative medicine.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara">See <a class="elsevierStyleCrossRef" href="#sec0005">Appendix A</a>.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Hospital Sant Pau (Barcelona)</span>: Pilar Paniagua, Mari Luz Maestre, Pablo Alonso-Coello, Marta De Antonio, Raúl Gonzalez, Adrià Font, Cecilia Martínez, Sonia Mirabet, Xavier Pelaez, Miquel Santaló, Jose Marcial Villamor.</p> <p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Hospital Gregorio Marañón Madrid</span>: Ignacio Garutti, Patricia Cruz, Carmen Fernández-Riveira, Maria Palencia, Patricia Piñeiro, Alberto Varela, Susana Díaz, Teresa del Castillo, Angeles de Miguel, Manuel Muñoz, Maria del Barrio, Gabriel Cusati, Alejandro Fernández, M. José Membrillo, Erika San Juan, Maite Torre, Mercedes García, Carolina Puertas, Hector Bueno, Pedro Luis Sánchez.</p>" "etiqueta" => "Appendix A" "titulo" => "Spanish VISION investigators" "identificador" => "sec0005" ] ] ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1641 "Ancho" => 2406 "Tamanyo" => 198642 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient management in the VISION study.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.J. 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Cruz received a grant from the <span class="elsevierStyleGrantSponsor"><span class="elsevierStyleItalic">Instituto de Salud Carlos III</span></span> (Beca FIS 2008-11).</p>" ] ] ] "idiomaDefecto" => "en" "url" => "/00349356/0000006000000006/v1_201308011352/S0034935612004276/v1_201308011352/en/main.assets" "Apartado" => array:4 [ "identificador" => "7569" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Editoriales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/00349356/0000006000000006/v1_201308011352/S0034935612004276/v1_201308011352/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935612004276?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 October | 1 | 0 | 1 |
| 2018 December | 1 | 0 | 1 |
| 2018 March | 1 | 0 | 1 |
| 2017 September | 0 | 1 | 1 |
| 2017 July | 16 | 3 | 19 |
| 2017 June | 18 | 13 | 31 |
| 2017 May | 31 | 2 | 33 |
| 2017 April | 20 | 2 | 22 |
| 2017 March | 20 | 2 | 22 |
| 2017 February | 23 | 7 | 30 |
| 2017 January | 21 | 3 | 24 |
| 2016 December | 33 | 6 | 39 |
| 2016 November | 38 | 9 | 47 |
| 2016 October | 54 | 7 | 61 |
| 2016 September | 28 | 6 | 34 |
| 2016 August | 35 | 7 | 42 |
| 2016 July | 31 | 7 | 38 |
| 2016 June | 32 | 12 | 44 |
| 2016 May | 18 | 10 | 28 |
| 2016 April | 20 | 5 | 25 |
| 2016 March | 25 | 6 | 31 |
| 2016 February | 15 | 9 | 24 |
| 2016 January | 28 | 6 | 34 |
| 2015 December | 36 | 15 | 51 |
| 2015 November | 13 | 8 | 21 |
| 2015 October | 32 | 10 | 42 |
| 2015 September | 29 | 8 | 37 |
| 2015 August | 19 | 3 | 22 |
| 2015 July | 21 | 4 | 25 |
| 2015 June | 11 | 3 | 14 |
| 2015 May | 15 | 5 | 20 |
| 2015 April | 14 | 9 | 23 |
| 2015 March | 18 | 4 | 22 |
| 2015 February | 23 | 4 | 27 |
| 2015 January | 17 | 2 | 19 |
| 2014 December | 32 | 6 | 38 |
| 2014 November | 17 | 3 | 20 |
| 2014 October | 23 | 3 | 26 |
| 2014 September | 21 | 3 | 24 |
| 2014 August | 18 | 4 | 22 |
| 2014 July | 14 | 6 | 20 |
| 2014 June | 15 | 4 | 19 |
| 2014 May | 5 | 0 | 5 |
| 2014 March | 0 | 1 | 1 |
| 2013 November | 2 | 1 | 3 |
| 2013 September | 1 | 1 | 2 |
| 2013 August | 2 | 4 | 6 |
| 2013 July | 4 | 3 | 7 |
| 2013 June | 2 | 0 | 2 |
| 2013 May | 123 | 0 | 123 |
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