Elevated Cardiac Troponin to Detect Acute Cellular Rejection After Cardiac Transplantation: A Systematic Review and Meta-Analysis.

Cardiac troponin is well known as a highly specific marker of cardiomyocyte damage, and has significant diagnostic accuracy in many cardiac conditions. However, the value of elevated recipient troponin in diagnosing adverse outcomes in heart transplant recipients is uncertain. We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception until December 2020. We generated summary sensitivity, specificity, and Bayesian areas under the curve (BAUC) using bivariate Bayesian modelling, and standardised mean differences (SMDs) to quantify the diagnostic relationship of recipient troponin and adverse outcomes following cardiac transplant. We included 27 studies with 1,684 cardiac transplant recipients. Patients with acute rejection had a statistically significant late elevation in standardised troponin measurements taken at least 1 month postoperatively (SMD 0.98, 95% CI 0.33-1.64). However, pooled diagnostic accuracy was poor (sensitivity 0.414, 95% CrI 0.174-0.696; specificity 0.785, 95% CrI 0.567-0.912; BAUC 0.607, 95% CrI 0.469-0.723). In summary, late troponin elevation in heart transplant recipients is associated with acute cellular rejection in adults, but its stand-alone diagnostic accuracy is poor. Further research is needed to assess its performance in predictive modelling of adverse outcomes following cardiac transplant. Systematic Review Registration: identifier CRD42021227861.

Prognostic Significance of Elevated Troponin in Adult Heart Transplant Recipients: A Systematic Review and Meta-Analysis.

OBJECTIVES: Cardiac troponin is a highly specific biomarker of myocardial injury that is of prognostic significance in a range of cardiovascular diseases. However, the prognostic value of elevated troponin in cardiac transplant recipients is uncertain. We aimed to evaluate the prognostic value of elevated cardiac troponin in predicting adverse recipient outcomes following heart transplant. MATERIALS AND METHODS: We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception until December 2020 and included studies reporting associations between elevated recipient troponin and outcomes after cardiac transplant. We generated summary odds ratios for associations with short- and long-term adverse events and used descriptive analyses where meta-analyses were inappropriate. RESULTS: We included 15 studies involving 1830 patients undergoing cardiac transplant. The risk of primary graft failure was greater in recipients with elevated troponin than in those without (odds ratio = 3.09; 95% CI, 1.08-8.87). Considerable interstudy heterogeneity (I2 statistic 98%) was partially explained by variations in study design, troponin subtype, and overall risk of bias. Descriptive analyses suggested associations between elevated recipient troponin and long-term adverse cardiac events, coronary artery disease, and mortality. CONCLUSIONS: Elevated cardiac troponin in cardiac transplant recipients may be prognostic for primary graft failure, adverse cardiac events, coronary artery disease, and mortality. Further high-quality, prospective, and multicenter research is needed to demonstrate the clinical applicability of these findings.

Donor Cardiac Troponin for Prognosis of Adverse Outcomes in Cardiac Transplantation Recipients: a Systematic Review and Meta-analysis.

BACKGROUND: Cardiac troponin is a highly specific and widely available marker of myocardial injury, and elevations in cardiac transplant donors may influence donor selection. We aimed to investigate whether elevated donor troponin has a role as a prognostic biomarker in cardiac transplantation. METHODS: In a systematic review and meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library, without language restriction, from inception to December 2020. We included studies reporting the association of elevated donor troponin with recipient outcome after cardiac transplant. We generated summary odds ratios and hazard ratios for the association of elevated donor troponin with short- and long-term adverse outcomes. Methodological quality was monitored using the Quality In Prognosis Studies tool, and interstudy heterogeneity was assessed using a series of sensitivity and subgroup analyses. RESULTS: We included 17 studies involving 15 443 patients undergoing cardiac transplantation. Elevated donor troponin was associated with increased odds of graft rejection at 1 y (odds ratio, 2.54; 95% confidence interval, 1.22-5.28). No significant prognostic relationship was found between donor troponin and primary graft failure, short- to long-term mortality, cardiac allograft vasculopathy, and pediatric graft loss. CONCLUSIONS: Elevated donor troponin is not associated with an increased short- or long-term mortality postcardiac transplant despite increasing the risk of graft rejection at 1 y. Accordingly, an elevated donor troponin in isolation should not exclude donation.

Interpretation of the four risk factors for postoperative nausea and vomiting in the Apfel simplified risk score: an analysis of published studies.

PURPOSE: The Apfel simplified risk score, developed in 1999, is the most widely used tool for risk stratification of postoperative nausea and vomiting (PONV). It includes four risk factors: female sex, non-smoking status, history of PONV or motion sickness, and use of postoperative opioids. Nevertheless, there is considerable heterogeneity in the definition and application of these risk factors in PONV research. Our aim was to determine how these risk factors are implemented in studies employing the Apfel score. METHODS: Citations of the index Apfel score paper between 1 September 1999 and 1 September 2019 were identified in the Scopus database. Original full-text reports in English measuring all four risk factors were eligible for inclusion. Data collected included the definition, timing, and collection method of the four risk factors. RESULTS: Of the identified studies, 255 of the 535 reported all four risk factors, with calculated Apfel risk scores reported in 116 of the 255 (46%) papers. Smoking, PONV, motion sickness, and postoperative opioid use were defined in four (2%), zero (0%), one (0.4%), and seven (3%) papers, respectively. Postoperative opioid use was defined as "anticipated" in 138 (54%) studies and "actual" in 72 (18%) studies and was unclear in 45 (28%) studies. CONCLUSIONS: Significant variation exists in how the Apfel risk factors are defined and applied in PONV research, particularly with respect to postoperative opioid use. More guidance in the application of this tool may optimize risk estimation and PONV prophylaxis, and potentially improve research quality.

RéSUMé: OBJECTIF: Le score simplifié d'Apfel, mis au point en 1999, est l'outil le plus utilisé pour la stratification des risques de nausées et vomissements postopératoires (NVPO). Il comprend quatre facteurs de risque : le sexe féminin, un statut de non-fumeur, les antécédents de NVPO ou de mal des transports, et l'utilisation d'opioïdes postopératoires. Néanmoins, il existe une hétérogénéité considérable dans la définition et l'application de ces facteurs de risque dans la recherche sur les NVPO. Notre objectif était de déterminer comment ces facteurs de risque étaient appliqués dans les études utilisant le score Apfel. MéTHODE: Les citations comportant dans leur index une mention du score d'Apfel entre le 1er septembre 1999 et le 1er septembre 2019 ont été identifiées dans la base de données Scopus. Les comptes rendus originaux en texte intégral en anglais mesurant les quatre facteurs de risque ont été inclus dans notre analyse. Les données recueillies comprenaient la définition, le moment et la méthode de collecte des quatre facteurs de risque. RéSULTATS: Parmi les études identifiées, 255 sur 535 documentaient les quatre facteurs de risque, et les scores d'Apfel calculés ont été rapportés dans 116 des 255 (46 %) articles. Le tabagisme, les NVPO, le mal des transports et l'utilisation postopératoire d'opioïdes ont été définis dans quatre (2 %), zéro (0 %), un (0,4 %) et sept (3 %) articles, respectivement. La consommation postopératoire d'opioïdes a été définie comme « anticipée ¼ dans 138 (54 %) études et « réelle ¼ dans 72 (18 %) études, et n'était pas claire dans 45 (28 %) études. CONCLUSION: Il existe d'importantes variations dans la façon dont les facteurs de risque d'Apfel sont définis et appliqués dans la recherche sur les NVPO, particulièrement en ce qui concerne l'utilisation postopératoire d'opioïdes. Des recommandations plus claires pour l'application de cet outil pourraient optimiser l'estimation des risques et la prophylaxie pour les NVPO, et potentiellement améliorer la qualité de la recherche.