Skip to main navigation menu Skip to main content Skip to site footer

Systematic review

Vol. 145 No. 4748 (2015)

Perioperative myocardial infarction/injury after noncardiac surgery

  • Christian Puelacher
  • Giovanna Lurati-Buse
  • Hélène Singeisen
  • Minh Dang
  • Florim Cuculi
  • Christian Müller
DOI
https://doi.org/10.4414/smw.2015.14219
Cite this as:
Swiss Med Wkly. 2015;145:w14219
Published
15.11.2015

Summary

Cardiovascular complications, particularly perioperative myocardial infarction/injury, seem to be major contributors to mortality after noncardiac surgery. With surgical procedures being very frequent (900 000/year in Switzerland), perioperative myocardial injury is common in everyday clinical practice. Over 80% of patients experiencing perioperative myocardial injury do not report symptoms. Therefore perioperative myocardial injury remains undiagnosed and untreated. Moreover, its silent presentation results in limited awareness among both clinicians and the public. Despite being largely asymptomatic, perioperative myocardial injury increases 30-day mortality nearly 10-fold. This review aims to increase the awareness of perioperative myocardial injury/infarction and give an overview of the emerging evidence, including pathophysiology, clinical presentation, prevention, and potential future treatments.

Summary: postoperative myocardial infarction/injury vs acute myocardial infarction

Currently, clinical awareness of PMI is often insufficient. To close this review, we want to compare PMI to a well-known and related disease, spontaneous AMI. First and most important, the vast majority of patients experiencing a PMI do not report acute chest pain or other symptoms typical of spontaneous AMI. Most likely, this is because these PMIs occur in a phase of intense postoperative analgesia [2, 3, 5, 7–9]. Accordingly, most patients with PMI are currently not detected in routine clinical practice. Missed diagnosis is invariably associated with a missed opportunity for the initiation of treatment. Second, the predominant pathophysiology of PMI is only incompletely characterised (plaque rupture versus supply/demand mismatch versus toxic) [14]. Third, because of our lack of knowledge regarding pathophysiology, it is unclear whether the benefit of treatment in PMI is similar to the huge benefit in spontaneous AMI. Fourth, in contrast to spontaneous MI, where cardiac troponin elevations must be accompanied by symptoms, electrocardiographic, or imaging criteria [10, 52], the limited applicability (chest pain in a period of intense postoperative analgesia) and sensitivity (ECG, imaging) of these criteria in the perioperative setting highlight the need for a different diagnostic approach for PMI, which needs to be defined.

References

  1. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139–144. doi:10.1016/S0140-6736(08)60878-8.
  2. Devereaux PJ, Chan MT V, Alonso-Coello P, et al. Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2012;307(21):2295–304. doi:10.1001/jama.2012.5502.
  3. Beattie WS, Karkouti K, Tait G, et al. Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery: a single-centre cohort study in 51,701 consecutive patients. Can J Anaesth. 2012;59(11):1013–22. doi:10.1007/s12630-012-9782-9.
  4. Van Waes J a R, Nathoe HM, de Graaff JC, et al. Myocardial injury after noncardiac surgery and its association with short-term mortality. Circulation. 2013;127(23):2264–71. doi:10.1161/CIRCULATIONAHA.113.002128.
  5. Devereaux PJ, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011;154(8):523–8. doi:10.7326/0003-4819-154-8-201104190-00003.
  6. Botto F, Alonso-Coello P, Chan MT V, et al. Myocardial Injury after Noncardiac Surgery: A Large, International, Prospective Cohort Study Establishing Diagnostic Criteria, Characteristics, Predictors, and 30-day Outcomes. Anesthesiology. 2014;120(3):564-578. doi:10.1097/ALN.0000000000000113.
  7. Ashton CM, Petersen NJ, Wray NP, et al. The incidence of perioperative myocardial infarction in men undergoing noncardiac surgery. Ann Intern Med. 1993;118(7):504–10.
  8. Badner NH, Knill RL, Brown JE, Novick T V, Gelb AW. Myocardial infarction after noncardiac surgery. Anesthesiology. 1998;88(3):572–8.
  9. Mangano DT, Browner WS, Hollenberg M, et al. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. N Engl J Med. 1990;323(26):1781–8. doi:10.1056/NEJM199012273232601.
  10. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Eur Heart J. 2012;33(20):2551–67. doi:10.1093/eurheartj/ehs184.
  11. Duvall WL, Sealove B, Pungoti C, Katz D, Moreno P, Kim M. Angiographic investigation of the pathophysiology of perioperative myocardial infarction. Catheter Cardiovasc Interv. 2012;80(5):768–76. doi:10.1002/ccd.23446.
  12. Gualandro DM, Campos CA, Calderaro D, et al. Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: frequent and dangerous. Atherosclerosis. 2012;222(1):191–5. doi:10.1016/j.atherosclerosis.2012.02.021.
  13. Hanson I, Kahn J, Dixon S, Goldstein J. Angiographic and clinical characteristics of type 1 versus type 2 perioperative myocardial infarction. Catheter Cardiovasc Interv. 2013;82(4):622-628. doi:10.1002/ccd.24626.
  14. Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009;119(22):2936–44. doi:10.1161/CIRCULATIONAHA.108.828228.
  15. Gualandro DM, Puelacher C, Mueller C. High-sensitivity cardiac troponin in acute conditions. Curr Opin Crit Care. 2014;20(5):472–7. doi:10.1097/MCC.0000000000000132.
  16. Landesberg G, Jaffe AS, Gilon D, et al. Troponin elevation in severe sepsis and septic shock: the role of left ventricular diastolic dysfunction and right ventricular dilatation*. Crit Care Med. 2014;42(4):790–800. doi:10.1097/CCM.0000000000000107.
  17. Wilhelm J, Hettwer S, Schuermann M, et al. Elevated troponin in septic patients in the emergency department: frequency, causes, and prognostic implications. Clin Res Cardiol. 2014;103(7):561–7. doi:10.1007/s00392-014-0684-4.
  18. Vasile VC, Chai H-S, Abdeldayem D, Afessa B, Jaffe AS. Elevated cardiac troponin T levels in critically ill patients with sepsis. Am J Med. 2013;126(12):1114–21. doi:10.1016/j.amjmed.2013.06.029.
  19. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesth. Eur Heart J. 2014;35:2383–431. doi:10.1093/eurheartj/ehu282.
  20. Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and Prospective Validation of a Simple Index for Prediction of Cardiac Risk of Major Noncardiac Surgery. Circulation. 1999;100(10):1043–9. doi:10.1161/01.CIR.100.10.1043.
  21. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC / AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery A Report of the American College of Cardiology / American Heart Association Task Force on Practice Guidelines.; 2014.
  22. Gupta PK, Gupta H, Sundaram A, et al. Development and validation of a risk calculator for prediction of cardiac risk after surgery. Circulation. 2011;124(4):381–7. doi:10.1161/CIRCULATIONAHA.110.015701.
  23. Weber M, Luchner A, Seeberger M, et al. Incremental value of high-sensitive troponin T in addition to the revised cardiac index for peri-operative risk stratification in non-cardiac surgery. Eur Heart J. 2013;34(11):853–62. doi:10.1093/eurheartj/ehs445.
  24. Feringa HHH, Bax JJ, Boersma E, et al. High-dose beta-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients. Circulation. 2006;114(1 Suppl):I344–I349. doi:10.1161/CIRCULATIONAHA.105.000463.
  25. Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839–47. doi:10.1016/S0140-6736(08)60601-7.
  26. Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/Ameri. J Am Coll Cardiol. 2014;64(22):2406–25. doi:10.1016/j.jacc.2014.07.939.
  27. Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003. doi:10.1093/eurheartj/eht296.
  28. Devereaux PJ, Sessler DI, Leslie K, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med. 2014;370(16):1494–503. doi:10.1056/NEJMoa1401105.
  29. Winjns W, Kolh PP, Danchin N, et al. Guidelines on myocardial revascularization. Rev Port Cardiol. 2010;29(9):1441–2. doi:10.1093/eurheartj/ehq277.
  30. Le Manach Y, Godet G, Coriat P, et al. The impact of postoperative discontinuation or continuation of chronic statin therapy on cardiac outcome after major vascular surgery. Anesth Analg. 2007;104(6):1326–33, table of contents. doi:10.1213/01.ane.0000263029.72643.10.
  31. Winchester DE, Wen X, Xie L, Bavry AA. Evidence of pre-procedural statin therapy a meta-analysis of randomized trials. J Am Coll Cardiol. 2010;56(14):1099–109. doi:10.1016/j.jacc.2010.04.023.
  32. Kaluza GL, Joseph J, Lee JR, et al. Catastrophic outcomes of noncardiac surgery soon after coronary stenting. J Am Coll Cardiol. 2000;35(5):1288–94. doi:10.1016/S0735-1097(00)00521-0.
  33. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med. 2004;351(27):2795–804. doi:10.1056/NEJMoa041905.
  34. Raymond J, Darsaut TE, Molyneux AJ. A trial on unruptured intracranial aneurysms (the TEAM trial): results, lessons from a failure and the necessity for clinical care trials. Trials. 2011;12:64. doi:10.1186/1745-6215-12-64.
  35. Lindholm EE, Aune E, Norén CB, et al. The anesthesia in abdominal aortic surgery (ABSENT) study: a prospective, randomized, controlled trial comparing troponin T release with fentanyl-sevoflurane and propofol-remifentanil anesthesia in major vascular surgery. Anesthesiology. 2013;119(4):802–12. doi:10.1097/ALN.0b013e31829bd883.
  36. Kristensen SD, Knuuti J. New ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management. Eur Heart J. August 2014:2344–5. doi:10.1093/eurheartj/ehu285.
  37. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368–75. doi:10.1056/NEJMsa0903048.
  38. Biccard BM, Rodseth RN. The pathophysiology of peri-operative myocardial infarction. Anaesthesia. 2010;65(7):733–41. doi:10.1111/j.1365-2044.2010.06338.x.
  39. Thompson JS, Baxter BT, Allison JG, Johnson FE, Lee KK, Park WY. Temporal patterns of postoperative complications. Arch Surg. 2003;138(6):596–602; discussion 602–603. doi:10.1001/archsurg.138.6.596.
  40. Nagele P, Brown F, Gage BF, et al. High-sensitivity cardiac troponin T in prediction and diagnosis of myocardial infarction and long-term mortality after noncardiac surgery. Am Heart J. 2013;166(2):325–32.e1. doi:10.1016/j.ahj.2013.04.018.
  41. Cunningham AJ. Myocardial ischemia – association with perioperative cardiac morbidity. Yale J Biol Med. 1993;66(5):339–48.
  42. Borutaite V, Toleikis A, Brown GC. In the eye of the storm: mitochondrial damage during heart and brain ischaemia. FEBS J. 2013;280(20):4999–5014. doi:10.1111/febs.12353.
  43. Moller JT, Johannessen NW, Espersen K, et al. Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications. Anesthesiology. 1993;78(3):445–53.
  44. Gögenur I, Rosenberg-Adamsen S, Lie C, Carstensen M, Rasmussen V, Rosenberg J. Relationship between nocturnal hypoxaemia, tachycardia and myocardial ischaemia after major abdominal surgery. Br J Anaesth. 2004;93(3):333–8. doi:10.1093/bja/aeh208.
  45. Landesberg G, Mosseri M, Zahger D, et al. Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia. J Am Coll Cardiol. 2001;37(7):1839–45.
  46. Crawford MH, Bernstein SJ, Deedwania PC, et al. ACC/AHA guidelines for ambulatory electrocardiography: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the guidelines for ambulatory el. Circulation. 1999;100(8):886–93. doi:10.1161/01.CIR.100.8.886.
  47. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60(16):1581–98. doi:10.1016/j.jacc.2012.08.001.
  48. Adesanya AO, de Lemos J a, Greilich NB, Whitten CW. Management of perioperative myocardial infarction in noncardiac surgical patients. Chest. 2006;130(2):584–96. doi:10.1378/chest.130.2.584.
  49. Alpert JS, Thygesen KA, White HD, Jaffe AS. Diagnostic and therapeutic implications of type 2 myocardial infarction: review and commentary. Am J Med. 2014;127(2):105–8. doi:10.1016/j.amjmed.2013.09.031.
  50. Saaby L, Poulsen TS, Hosbond S, et al. Classification of myocardial infarction: frequency and features of type 2 myocardial infarction. Am J Med. 2013;126(9):789–97. doi:10.1016/j.amjmed.2013.02.029.
  51. Bhandari M, Sc M, Guyatt G, et al. Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis. Anesthesiology. 2011;114(4):796–806. doi:10.1097/ALN.0b013e31820ad503.
  52. Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Eur Heart J. 2007;28(20):2525–38. doi:10.1093/eurheartj/ehm355.

Most read articles by the same author(s)