Perioperative myocardial ischaemia, heart rate and arrhythmia in patients undergoing thoracotomy: an observational study

Groves, Jay; Edwards, N. D.; Carr, Benjamin M.; Sherry, K.M.

doi:10.1093/bja/83.6.850

Cited by 23 publications

(6 citation statements)

References 22 publications

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“…Postoperative myocardial ischaemia is more common than pre‐and intra‐operative myocardial ischaemia [3, 24, 26, 27]. The duration of postoperative myocardial ischaemia generally exceeds that of pre‐ or intra‐operative myocardial ischaemia [3, 28].…”

Section: The Pathophysiology Of Peri‐operative Myocardial Infarctionmentioning

confidence: 99%

The pathophysiology of peri‐operative myocardial infarction

Bm¹,

Rodseth

2010

Anaesthesia

119

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SummaryIt is generally believed that plaque rupture and myocardial oxygen supply-demand imbalance contribute approximately equally to the burden of peri-operative myocardial infarction. This review critically analyses data of post-mortem, pre-operative coronary angiography, troponin surveillance, other pre-operative non-invasive investigations, and peri-operative haemodynamic predictors of myocardial ischaemia and ⁄ or myocardial infarction. The current evidence suggests that myocardial oxygen supply-demand imbalance predominates in the early postoperative period. It is likely that flow stagnation and thrombus formation is an important pathway in the development of a peri-operative myocardial infarction, in addition to the more commonly recognised role of peri-operative tachycardia. Research and therapeutic interventions should be focused on the prediction and therapy of flow stagnation and thrombus formation. Plaque rupture appears to be a more random event, distributed over the entire peri-operative admission. Patients with or at risk of cardiac disease have a 3.9% (95% CI 3.3-4.6%) risk of suffering a major peri-operative cardiac event [1]. A peri-operative myocardial infarction has an associated in-hospital mortality of 15-25% [1] and an increased risk of subsequent cardiovascular death or myocardial infarction [2].Despite this important prognostic information, there are a number of controversial and poorly understood issues surrounding peri-operative myocardial infarction. There is well established evidence that an increasing heart rate is associated with peri-operative myocardial ischaemia and myocardial infarction [3]. However, substantial evidence suggests that hypotension, hypoperfusion and coagulation are important precipitants of early peri-operative myocardial ischaemia and infarction. Understanding peri-operative myocardial infarction pathophysiology is important in addressing appropriate peri-operative therapies, which in turn have important public health implications. Presentation of peri-operative myocardial infarctionTime of presentation Since the introduction of troponin surveillance, most perioperative myocardial infarctions are identified within the first postoperative day [4], compared with identification between 48 and 72 h when creatine phosphokinase was used. The day of presentation [5][6][7] of a peri-operative myocardial infarction is shown in Fig. 1.Although the majority of peri-operative myocardial infarctions present within the first 4 days of surgery, and nearly 90% by 7 days, the range of presentation is throughout the entire hospital admission [7]. After the seventh postoperative day approximately 1% of perioperative myocardial infarctions present per day [5][6][7].Pattern of presentation of troponin elevation A study of aortic surgical patients identified three patterns of troponin elevation [8]. The first pattern was characterised

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Section: The Pathophysiology Of Peri‐operative Myocardial Infarctionmentioning

confidence: 99%

The pathophysiology of peri‐operative myocardial infarction

Bm¹,

Rodseth

2010

Anaesthesia

119

View full text Add to dashboard Cite

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“…Postoperative myocardial ischaemia occurs more commonly and for a longer time period than both pre-and intraoperative myocardial ischaemia, [20][21][22][23][24] and ST-segment depression has been identified in up to 20% of vascular surgical patients. 25 Furthermore, postoperative myocardial ischaemia (> 10 minutes) independently predicts troponin elevation (OR 3.88, 95% CI: 2.03-8.74, p-value < 0.0001), 25 and correlation has been shown with troponin and ischaemic Manipulation of postoperative heart rate and haemoglobin concentration may prevent or modify the frequency and severity of these events.…”

Section: Intra-and Postoperative Risk Predictorsmentioning

confidence: 99%

Preoperative B-type natriuretic peptide risk stratification: do postoperative indices add value?

Rodseth

Vasconcellos²,

Naidoo

et al. 2013

Southern African Journal of Anaesthesia and Analgesia

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“…Heart rate and associated perioperative myocardial ischaemia will be discussed separately in a later generated a substantial research base in an attempt Preoperative heart rate Surprisingly, there are few studies that analyse preoperative heart rate as a predictor of perioperative myocardial infarction or cardiac morbidity 42 , with the majority ignoring it 1,2,4,5,48 . This may be because of the importance of heart rate as a potential cardiovascular risk factor has been appreciated only recently 11 .…”

Section: Adverse Outcomes Associated With Perioperative Heart Rate In Surgical Patientsmentioning

confidence: 99%

“…Heart rate has been shown to be an important determinant of various outcomes including survival 15,[38][39][40][41] and both cardiac 39,[42][43][44][45] and noncardiac 44 complications in patients undergoing major noncardiac surgery. Important characteristics of the perioperative heart rate that need to be considered when discussing associated outcomes include the absolute heart rate 15,39,41,43 , the absolute change in heart rate 39 and the lability 46,47 of the perioperative heart rate.…”

Section: Adverse Outcomes Associated With Perioperative Heart Rate In Surgical Patientsmentioning

confidence: 99%

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Heart Rate and Outcome in Patients with Cardiovascular Disease Undergoing Major Noncardiac Surgery

2008

Anaesth Intensive Care

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There is an increasing awareness that an elevated resting heart rate is associated with increased all-cause mortality in the general population and that this may be an independent coronary risk factor. This review was undertaken to determine whether heart rate is predictive of increased mortality and major morbidity in noncardiac surgical patients and whether heart rate manipulation improves perioperative outcome. A search of Medline from 1966 until October 2007 was conducted using the terms "heart rate", "surgery", "cardiac", "morbidity", "mortality" and "perioperative". The main findings were that an elevated perioperative heart rate, an absolute increase in heart rate and heart rate lability are independent predictors of both short-and long-term adverse outcomes in patients at cardiovascular risk undergoing major noncardiac surgery. Although prospective nonrandomised and retrospective data suggest heart rate control improves perioperative outcome, there is conflicting evidence from randomised trials that perioperative heart rate control improves outcome. This may be because drug-associated bradycardia influences mortality in the perioperative period. Further studies reporting the absolute heart rate, the absolute change of heart rate and the time period of the observations are needed to identify 'early warning systems', which may allow earlier triage and improved outcome. Enthusiasm for this approach must be tempered by the appreciation that a J-shaped relationship probably exists between heart rate and morbidity, particularly following bradycardic therapy. Therefore, any bradycardic manipulation of heart rate in the perioperative period must be accompanied by simultaneous attention to other physiological variables associated with increased morbidity and mortality.

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Perioperative myocardial ischaemia, heart rate and arrhythmia in patients undergoing thoracotomy: an observational study

Cited by 23 publications

References 22 publications

The pathophysiology of peri‐operative myocardial infarction

The pathophysiology of peri‐operative myocardial infarction

Preoperative B-type natriuretic peptide risk stratification: do postoperative indices add value?

Heart Rate and Outcome in Patients with Cardiovascular Disease Undergoing Major Noncardiac Surgery

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