Perioperative myocardial infarction in non-cardiac surgery. Pathophysiology and clinical implications

Abstract

Advances in surgical and anaesthetic techniques and an aging patient population have resulted in more complex procedures being performed in greater numbers of aged subjects and in patients with a high likelihood of significant cardiovascular disease. Nearly one fourth of non-cardiac surgical procedures (major intra-abdominal, thoracic, vascular, and orthopaedic procedures) performed in persons older than 65 years have been found to be associated with significant perioperative cardiovascular morbidity and mortality. During previous years the main attempt was to define strategies to accurately estimate perioperative cardiovascular risk based either on the characteristics of surgery and on patient characteristics. More recently preventive medical strategies have been proposed. Therefore, the physician has to be aware of the key elements useful to calculate the perioperative cardiovascular risk, and of the medical preventive treatment or further interventions to adopt in patients candidate to surgery.

Application of Cardiac Troponin in Cardiovascular Diseases Other Than Acute Coronary Syndrome

“…The majority of patients with perioperative myocardial injury do not have classical type 1 MI and go clinically undetected. Imbalance in myocardial oxygen supply/demand causing ischemic injury, e.g., in case of perioperative hypotension tachycardia or fever, is probably the most common cause of perioperative myocardial injury with increase in cardiac troponin (type 2 MI) (49,52,53 ). Patients with preexisting coronary artery disease are at a particular ischemic risk.…”

Regarding “The association of perioperative transfusion with 30-day morbidity and mortality in patients undergoing major vascular surgery”

“…Certainly, many positive findings in retrospective studies have been disproven in large randomized controlled trials; the use of compression stockings for treatment of post-thrombotic syndrome is one such example, with the recently completed SOX randomized controlled trial failing to demonstrate any such benefit. 1 However, within the confines of a retrospective study, we argue that this study is valuable in what it providesda very large (several thousand patients larger than the next largest study specific to vascular patients 2 )…”

“…In our view, however, two issues of this study should be clarified and discussed.First, health status, comorbidities, and operative risk are important determinants for postoperative morbidity and mortality. 2 In this study, patients receiving a transfusion had multiple baseline differences compared with those not receiving a transfusion; transfused patients were more likely to have preoperative anemia, cardiovascular diseases, diabetes mellitus, cerebrovascular accident, and renal failure requiring hemodialysis. Moreover, transfused patients were more likely to undergo open abdominal aortic aneurysm repair, open revascularization bypass, and urgent surgery.…”

Role of preoperative electrocardiography in predicting cardiovascular complications in proximal femur surgery

“…Whereas ECG has been shown to be ineffective in determining perioperative cardiac risk in low-risk surgeries, routine ECG is recommended before intermediate-risk surgeries where there are ≥1 clinical risk factors or an existing vascular disease in the patient history (1). Cardiac complications that lead to mortality and morbidity develop in approximately 5% of orthopedic surgeries in patients who are at intermediate risk in terms of perioperative cardiovascular complications (PCVCs) (2). Because most cardiac complications are treatable, prediction and/or early diagnosis are vital.…”