Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association

Abstract

Myocardial injury after noncardiac surgery is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay and are attributable to a presumed ischemic mechanism, with or without concomitant symptoms or signs. Myocardial injury after noncardiac surgery occurs in ≈20% of patients who have major inpatient surgery, and most are asymptomatic. Myocardial injury after noncardiac surgery is independently and strongly associated with both short-term and long-term mortality, even in the absence of clinical symptoms, electrocardiographic changes, or imaging evidence of myocardial ischemia consistent with myocardial infarction. Consequently, surveillance of myocardial injury after noncardiac surgery is warranted in patients at high risk for perioperative cardiovascular complications. This scientific statement provides diagnostic criteria and reviews the epidemiology, pathophysiology, and prognosis of myocardial injury after noncardiac surgery. This scientific statement also presents surveillance strategies and treatment approaches.

Enhanced peri‐operative care to improve outcomes for high‐risk surgical patients in Brazil: a single‐centre before‐and‐after cohort study

“…We reduced failure‐to‐rescue events by facilitating standardised clinical pathways including frequent vital signs monitoring, pro‐active patient care led by qualified nursing staff and prompt access to medical support when required. According to current international guidelines recommendations [33], we added the biomarker troponin in the protocol as an objective measure to scale up care for high‐risk patients experiencing asymptomatic peri‐operative myocardial injury [34]. However, improved survival identified in this study is unlikely to relate to inclusion of troponin within the intervention bundle, as relatively few cardiology referrals or auxiliary teams were triggered as a result of this measure.…”

“…We reduced failure-to-rescue events by facilitating standardised clinical pathways including frequent vital signs monitoring, pro-active patient care led by qualified nursing staff and prompt access to medical support when required. According to current international guidelines recommendations [33], we added the biomarker troponin in the protocol as an objective measure to scale up care for high-risk patients experiencing asymptomatic peri-operative myocardial injury [34].…”

Myocardial injury after noncardiac surgery

“…12 And in 2021, an American Heart Association scientific statement on MINS stated that ''high-risk individuals should have serial cTn measurements during the first 48 to 72 hr postoperatively.'' 13 Thus, there is a fairly broad consensus that troponin screening is indicated in at-risk patients, and recent work suggests that implementation is feasible and cost effective in the Canadian context. 14 VISION cost-consequence analyses support perioperative troponin monitoring in patients C 65 yr of age or with a history of atherosclerotic disease.…”

“…12 Et en 2021, un e ´nonce ścientifique de l'American Heart Association concernant les MINS de ´clarait que « les personnes a `haut risque devraient avoir des mesures des cTn (troponines cardiaques) re ´pe ´te ´es au cours des 48 a `72 premie `res heures postope ´ratoires ». 13 Ainsi, le consensus est assez large sur le fait que le dosage des troponines est indique 123 chez les patients a `risque, et des travaux re ´cents sugge `rent que la mise en oeuvre d'une telle mesure est re ´alisable et rentable dans le contexte canadien. 14 Les analyses cou ˆts-conse ´quences de l'e ´tude VISION appuient le monitorage pe ´riope ´ratoire des troponines chez les patients a ˆge ´s de C 65 ans ou ayant des ante ´ce ´dents d'athe ´roscle ´rose.…”

Risk factors, transcriptomics, and outcomes of myocardial injury following lower extremity revascularization

“…In a retrospective study of surgical hospitalizations in the United States, perioperative death, myocardial infarction (MI), or ischemic stroke occurred in 3% of non-cardiac surgeries 3 . However, ischemic symptoms may be masked by post-operative anesthesia and analgesia, and many cardiovascular complications may go unrecognized 4 . Myocardial injury after non-cardiac surgery (MINS), with or without evidence of MI, is a common syndrome that is characterized by ≥ 1 troponin concentrations that exceed the 99th percentile upper reference limit of the assay, detected in 16–20% of patients after major operative procedures, and independently associated with short-term mortality 4 – 6 .…”