Expert consensus on peri-operative myocardial injury screening in noncardiac surgery

Puelacher, Christian; Pinto, Bernardo Bollen; Mills, Nicholas L; Duceppe, Emmanuelle; Popova, Ekaterine; Duma, Andreas; Nägele, Peter; Omland, Torbjørn; Hammerer-Lercher, Angelika; Buse, Giovanna Lurati

doi:10.1097/eja.0000000000001486

Cited by 39 publications

(33 citation statements)

References 57 publications

(154 reference statements)

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“…Both a type I (coronary thrombus) and type II (oxygen supply/demand mismatch) aetiology have been proposed, but coronary angiographic studies suggest a mainly type II aetiology during AECOPD and in peri-operative myocardial infarction. [26][27][28][29][30][31][32] The associations of hypoxaemia, tachycardia and respiratory rate with myocardial injury found in our study support the theory of type II aetiology to largely contribute to myocardial injury. Additional studies of specific combinations of vital sign deviations prior to myocardial injury or further diagnostic examinations such as coronary angiography in patients with myocardial injury are warranted for further understanding of the pathophysiology.…”

Section: Hypotensionsupporting

confidence: 78%

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Continuously monitored vital signs for detection of myocardial injury in high‐risk patients – An observational study

Loft

Rasmussen

Elvekjær

et al. 2022

Acta Anaesthesiol Scand

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Background Patients are at risk of myocardial injury after major non‐cardiac surgery and during acute illness. Myocardial injury is associated with mortality, but often asymptomatic and currently detected through intermittent cardiac biomarker screening. This delays diagnosis, where vital signs deviations may serve as a proxy for early signs of myocardial injury. This study aimed to assess the association between continuous monitored vital sign deviations and subsequent myocardial injury following major abdominal cancer surgery and during acute exacerbation of chronic obstructive pulmonary disease. Methods Patients undergoing major abdominal cancer surgery or admitted with acute exacerbation of chronic obstructive pulmonary disease had daily troponin measurements. Continuous wireless monitoring of several vital signs was performed for up to 96 h after admission or surgery. The primary exposure was cumulative duration of peripheral oxygen saturation (SpO2) below 85% in the 24 h before the primary outcome of myocardial injury, defined as a new onset ischaemic troponin elevation assessed daily. If no myocardial injury occurred, the primary exposure was based on the first 24 h of measurement. Results A total of 662 patients were continuously monitored and 113 (17%) had a myocardial injury. Cumulative duration of SpO2 < 85% was significantly associated with myocardial injury (mean difference 14.2 min [95% confidence interval −4.7 to 33.1 min]; p = .005). Durations of hypoxaemia (SpO2 < 88% and SpO2 < 80%), tachycardia (HR > 110 bpm and HR > 130 bpm) and tachypnoea (RR > 24 min−1 and RR > 30 min−1) were also significantly associated with myocardial injury (p < .04, for all). Conclusion Duration of severely low SpO2 detected by continuous wireless monitoring is significantly associated with myocardial injury in high‐risk patients admitted to hospital wards. The effect of early detection and interventions should be assessed next.

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Section: Hypotensionsupporting

confidence: 78%

“…The aetiology of myocardial injury is not always clear. Both a type I (coronary thrombus) and type II (oxygen supply/demand mismatch) aetiology have been proposed, but coronary angiographic studies suggest a mainly type II aetiology during AECOPD and in peri‐operative myocardial infarction 26‐32 …”

Section: Discussionmentioning

confidence: 99%

Continuously monitored vital signs for detection of myocardial injury in high‐risk patients – An observational study

Loft

Rasmussen

Elvekjær

et al. 2022

Acta Anaesthesiol Scand

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“…Currently no guideline-endorsed management recommendations exist, but opinion papers outlining such screening and response systems can be considered. 26 Third, following revision surgery for PJI, patients showed a significantly higher mortality rate at 30 days and one year than the aseptic control group, with one in six patients dying within one year. After adjustment for the multivariable analysis, statistical significance could not be confirmed.…”

Section: Discussionmentioning

confidence: 92%

“…Currently no guideline-endorsed management recommendations exist, but opinion papers outlining such screening and response systems can be considered. 26…”

Section: Discussionmentioning

confidence: 99%

Perioperative myocardial injury and mortality after revision surgery for orthopaedic device-related infection

Kvarda

Puelacher

Clauss

et al. 2022

The Bone & Joint Journal

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Aims Periprosthetic joint infections (PJIs) and fracture-related infections (FRIs) are associated with a significant risk of adverse events. However, there is a paucity of data on cardiac complications following revision surgery for PJI and FRI and how they impact overall mortality. Therefore, this study aimed to investigate the risk of perioperative myocardial injury (PMI) and mortality in this patient cohort. Methods We prospectively included consecutive patients at high cardiovascular risk (defined as age ≥ 45 years with pre-existing coronary, peripheral, or cerebrovascular artery disease, or any patient aged ≥ 65 years, plus a postoperative hospital stay of > 24 hours) undergoing septic or aseptic major orthopaedic surgery between July 2014 and October 2016. All patients received a systematic screening to reliably detect PMI, using serial measurements of high-sensitivity cardiac troponin T. All-cause mortality was assessed at one year. Multivariable logistic regression models were applied to compare incidence of PMI and mortality between patients undergoing septic revision surgery for PJI or FRI, and patients receiving aseptic major bone and joint surgery. Results In total, 911 consecutive patients were included. The overall perioperative myocardial injury (PMI) rate was 15.4% (n = 140). Septic revision surgery for PJI was associated with a significantly higher PMI rate (43.8% (14/32) vs 14.5% (57/393); p = 0.001) and one-year mortality rate (18.6% (6/32) vs 7.4% (29/393); p = 0.038) compared to aseptic revision or primary arthroplasty. The association with PMI persisted in multivariable analysis with an adjusted odds ratio (aOR) of 4.7 (95% confidence interval (CI) 2.1 to 10.7; p < 0.001), but was not statistically significant for one-year mortality (aOR 1.9 (95% CI 0.7 to 5.4; p = 0.240). PMI rate (15.2% (5/33) vs 14.1% (64/453)) and one-year mortality (15.2% (5/33) vs 9.1% (41/453)) after FRI revision surgery were comparable to aseptic long-bone fracture surgery. Conclusion Patients undergoing revision surgery for PJI were at a risk of PMI and death compared to those undergoing aseptic arthroplasty surgery. Screening for PMI and treatment in specialized multidisciplinary units should be considered in major bone and joint infections. Cite this article: Bone Joint J 2022;104-B(6):696–702.

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“…Hence, patients with APMI should be more closely monitored after discharge and possibly referred to a cardiologist for evaluation. In addition, it is speculated that enhanced monitoring and appropriate drug intervention such as aspirin, betalox, statins, and other drugs might benefit the patients, 24 , 31 but further large-scale clinical trials are needed for confirmation.…”

Section: Discussionmentioning

confidence: 99%

Association of Acute Perioperative Myocardial Injury With All-Cause Mortality Within 90 Days After Hip Fracture Repair in the Elderly: A Prospective Study

Wang

Cai

et al. 2022

Geriatr Orthop Surg Rehabil

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Introduction It remains unclear whether acute perioperative myocardial injury (APMI) increases mortality in the elderly. This study aimed to investigate APMI’s association with mortality within 90 days after hip fracture repair in elderly patients. Materials and Methods This prospective study enrolled elderly patients admitted to the department of Traumatology and Orthopaedics in XXX Hospital, who underwent surgery in 2018–2019 with a 90-day follow-up. According to survival status within 90 days, survival and death groups were constituted. Clinical, demographic, and laboratory indicators and 90-day mortality post-surgery were recorded. APMI’s association with 90-day mortality post-surgery was analyzed by logistic regression. Results Totally 248 participants were enrolled, including 224 and 24 in the survival and death groups, respectively, for a mortality rate of 9.7%. Compared with surviving individuals, the death group was older [81 (75–86) vs 87 (82–89) years], and had higher incidence rates of APMI (24.6% vs 58.3%), intertrochanteric fractures (41.1% vs 62.5%), preoperative atrial fibrillation (8.9% vs 29.2%), and dementia (73.7% vs 95.8%) (all P<.05). They also showed higher pre-injury frail scale scores [1 (0–2) vs 3 (1–4)] and Nottingham hip fracture scores (NHFSs) [4 (4–5) vs 6.5 (5–7)], lower Glomerular filtration [62 (46.1–78.6) vs 44.37 (35–61.92) ml/min], and reduced odds of glomerular filtration rate <60 mL/min (75.0% vs 46.9%) (all P < .05). APMI (OR = 3.294, 95% CI: 1.217–8.913) and NHFS (OR = 2.089, 95% CI: 1.353–3.225) independently predicted 90-day mortality post-surgery (all P<.05). Conclusions APMI is associated with increased mortality risk within 90 days after hip fracture repair in elderly patients.

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Expert consensus on peri-operative myocardial injury screening in noncardiac surgery

Cited by 39 publications

References 57 publications

Continuously monitored vital signs for detection of myocardial injury in high‐risk patients – An observational study

Continuously monitored vital signs for detection of myocardial injury in high‐risk patients – An observational study

Perioperative myocardial injury and mortality after revision surgery for orthopaedic device-related infection

Association of Acute Perioperative Myocardial Injury With All-Cause Mortality Within 90 Days After Hip Fracture Repair in the Elderly: A Prospective Study

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