MINS and BNP

[jope]

Hi all,

I work in Canada and I wanted to get some of your opinions on the latest (CCS) Canadian Cardiovascular Society Guidelines.

http://www.onlinecjc.ca/article/S0828-282X(16)30980-1/abstract

Compared to the American AHA guidelines, the new recommendation for us is now to forgo most of the invasive/procedural testing and do a BNP in the patient and then to monitor for troponin rise in those that are deemed high risk. Potential cost savings are pretty big. It costs about $20 CDN to run a point of care BNP sample here. The CCS guidelines are also easier to follow than the AHA guidelines.

I was wondering if any of you have started integrating BNP into your practice in the perioperative setting? Thanks.

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[Dr.whom]

I don’t measure bnp or routine post op troponins. Im curious about what kind of cases you do this for. Do you do it for minor or outpatient surgery?

 

[anbuitachi]

Hi all,

I work in Canada and I wanted to get some of your opinions on the latest (CCS) Canadian Cardiovascular Society Guidelines.

http://www.onlinecjc.ca/article/S0828-282X(16)30980-1/abstract

Compared to the American AHA guidelines, the new recommendation for us is now to forgo most of the invasive/procedural testing and do a BNP in the patient and then to monitor for troponin rise in those that are deemed high risk. Potential cost savings are pretty big. It costs about $20 CDN to run a point of care BNP sample here. The CCS guidelines are also easier to follow than the AHA guidelines.

I was wondering if any of you have started integrating BNP into your practice in the perioperative setting? Thanks.

It's pretty uncommon to get invasive testing for a procedure from my experience for non cardiac surgery. Maybe for people with positive stress test scheduled for major procedure. But to me this feels really rare. Out of all the patients you take care of in the OR, how many have positive stress tests? And how many of those have really major abnormalities on stress? And out of those how many are undergoing major surgery? Unless you've had zero medical care in the past, most patients with really abnormal stress tests probably have symptoms with exertion and have already seen cardiologists prior to needing the surgery and has had their issues addressed.

It seems more like a medicine/cardiology thing to do than anesthesiology.

 

[deleted875186]

The articles point about the RCRI as opposed to other risk calculators is interesting. Is a troponin rise in a patient after surgery without any other signs or symptoms really that significant. I guess it’s a type 2 MI by definition, but I don’t know if it warrants monitoring tropnon post op in all high risk patients.

 

[jope]

At our center, we are starting to have this protocol to check BNPs in patients >65 or having at least one point on RCRI in the preoperative clinic. Any patients that hit the > 300 threshold for NT-proBNP gets put on a perioperative medicine list where the out-of-OR/APS anesthesiologist will followup on the computer system for a couple days to see if they have a troponin rise. If they do, they will see the patient and usually refer to Internal Medicine for followup and therapy intensification with statins/ASA. One group that routinely gets this test here are the orthopedics and vascular patients that often can't do 4 METs clearly due to mobility limitations or claudication. By the AHA guidelines, all of these vascular patients that can't do 4 METs should undergo further testing, but doing a BNP lets us avoid that.

Finally, on my first though, a slight rise in troponin postop likely isn't a big deal. However, it has been shown that an asyptomatic rise in troponin (MINS) is association with increased 30-day mortality.

RESULTS:
Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom.

CONCLUSIONS AND RELEVANCE:
Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.

Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surg... - PubMed - NCBI

 

[deleted875186]

Logically I don’t see how a troponin bump after surgery in and of itself would lead to increased mortality. I would guess it’s just an association, sicker people tend to get a troponin bump. Do we think intensifying their medical therapy is actually going to do much?

 

[anbuitachi]

At our center, we are starting to have this protocol to check BNPs in patients >65 or having at least one point on RCRI in the preoperative clinic. Any patients that hit the > 300 threshold for NT-proBNP gets put on a perioperative medicine list where the out-of-OR/APS anesthesiologist will followup on the computer system for a couple days to see if they have a troponin rise. If they do, they will see the patient and usually refer to Internal Medicine for followup and therapy intensification with statins/ASA. One group that routinely gets this test here are the orthopedics and vascular patients that often can't do 4 METs clearly due to mobility limitations or claudication. By the AHA guidelines, all of these vascular patients that can't do 4 METs should undergo further testing, but doing a BNP lets us avoid that.

Finally, on my first though, a slight rise in troponin postop likely isn't a big deal. However, it has been shown that an asyptomatic rise in troponin (MINS) is association with increased 30-day mortality.

RESULTS:
Among 21 842 participants, the mean age was 63.1 (SD, 10.7) years and 49.1% were female. Death within 30 days after surgery occurred in 266 patients (1.2%; 95% CI, 1.1%-1.4%). Multivariable analysis demonstrated that compared with the reference group (peak hsTnT <5 ng/L), peak postoperative hsTnT levels of 20 to less than 65 ng/L, 65 to less than 1000 ng/L, and 1000 ng/L or higher had 30-day mortality rates of 3.0% (123/4049; 95% CI, 2.6%-3.6%), 9.1% (102/1118; 95% CI, 7.6%-11.0%), and 29.6% (16/54; 95% CI, 19.1%-42.8%), with corresponding adjusted HRs of 23.63 (95% CI, 10.32-54.09), 70.34 (95% CI, 30.60-161.71), and 227.01 (95% CI, 87.35-589.92), respectively. An absolute hsTnT change of 5 ng/L or higher was associated with an increased risk of 30-day mortality (adjusted HR, 4.69; 95% CI, 3.52-6.25). An elevated postoperative hsTnT (ie, 20 to <65 ng/L with an absolute change ≥5 ng/L or hsTnT ≥65 ng/L) without an ischemic feature was associated with 30-day mortality (adjusted HR, 3.20; 95% CI, 2.37-4.32). Among the 3904 patients (17.9%; 95% CI, 17.4%-18.4%) with MINS, 3633 (93.1%; 95% CI, 92.2%-93.8%) did not experience an ischemic symptom.

CONCLUSIONS AND RELEVANCE:
Among patients undergoing noncardiac surgery, peak postoperative hsTnT during the first 3 days after surgery was significantly associated with 30-day mortality. Elevated postoperative hsTnT without an ischemic feature was also associated with 30-day mortality.

Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surg... - PubMed - NCBI

The question is after that referral, what is being done? Are they just continuing to trend to trop to see it come down? Are they doing caths?? And is it actually improving 1 year mortality?

 

[fakin' the funk]

The cool thing is that if you check a lot of troponins you will find a lot of trivial troponin bumps.