This resource center is jointly hosted by The American Journal of Medicine,
The American Journal of Cardiology, and the Canadian Journal of Cardiology.

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Key Highlights

  • Examined a cohort of 667 consecutive major vascular surgery patients with an elevated postoperative Troponin I level to determine which patients received medical therapy as per the 2007 American College of Cardiology/American Heart Association recommendations for the medical management of patients with chronic stable angina.
  • The relationship of medical management consistent with guidelines with 12-month survival without a major cardiac event (ie, death, myocardial infarction, coronary revascularization, or pulmonary edema requiring hospitalization) was examined.

Key Findings

  • Therapy was intensified in 43 of 66 patients (65%) who suffered a Troponin I elevation after surgery.
  • Patients with a Troponin I elevation who did not receive intensified cardiovascular treatment had a hazard ratio (HR) of 1.77 (95% confidence interval (CI), 1.13–2.42; P = 0.004) for the primary study outcome as compared with the control group.
  • In contrast, patients with a Troponin I elevation who received intensified cardiovascular treatment had an HR of 0.63 (95% CI, 0.10–1.19; P = 0.45) for the primary outcome as compared with the control group.
  • In patients with elevated Troponin I levels after non-cardiac surgery, long-term adverse cardiac outcomes are likely improved by following evidence-based recommendations for the medical management of acute coronary syndromes, though investigators concluded that this effect needed to be confirmed in a large, randomized, controlled trial.


Devereaux PJ, Duceppe E, Guyatt G, et al on behalf of the MANAGE Invesitgators. Lancet 2018; 391:2325–2334


  • MANAGE trial is an international, multicenter, randomized controlled trial with partial 2x2 factorial design involving 84 centers in 19 countries.
  • Participants aged ≥45 who underwent noncardiac surgery and sustained a myocardial infarction after noncardiac surgery (MINS) were included in the trial.
  • The study randomized 1754 patients to dabigatran or placebo and 556 patients were randomized to omeprazole or placebo.


  • Compared to placebo, the use of dabigatran reduced major vascular complications (ie, a composite of vascular mortality, nonfatal MI, non-hemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic VTE) by a hazard ratio of 0.72.
  • In terms of primary safety outcome (i.e. a composite of life-threatening, major, and critical organ bleed), there was no significant difference between dabigatran and placebo.
  • MANAGE demonstrated that the use of dabigatran could prevent major vascular complications with no observed increased risk of major bleeding.


Featured Articles

Devereaux PJ, Sessler DI. N Engl J Med. 2015;373:2258-2269. doi: 10.1056/NEJMra1502824
Duceppe E, Parlow J, MacDonald P, et al. Can J Cardiol. 2016 Oct 4. pii: S0828-282X(16)30980-1. doi: 10.1016/j.cjca.2016.09.008
Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators, Devereaux PJ, Chan MT, et al. JAMA. 2012;307:2295-304