High-Sensitivity Troponin Levels, Ischemia, and Mortality—Reply

In Reply Dr Smilowitz points out that some patients who had sepsis or atrial fibrillation and were adjudicated as having a nonischemic etiology as the cause of their elevated hsTnT measurements after noncardiac surgery actually may have had an imbalance in myocardial oxygen supply and demand (ie, an ischemic etiology). We agree with his comment; however, this is often difficult to determine clinically. In the VISION study, expert physician adjudicators evaluated all elevated hsTnT measurements and determined if there was evidence that the hsTnT elevation was due to a nonischemic etiology (eg, sepsis, pulmonary embolus, atrial fibrillation, cardioversion, chronic elevation). The adjudicators had access to all the medical records related to these events, and we accepted their expert opinion when they decided the evidence supported that the elevated hsTnT was due to a nonischemic etiology. They may have labeled some events as having a nonischemic etiology when the elevated hsTnT was actually due to an ischemic etiology and represented MINS.