Perioperative myocardial infarction—aetiology and prevention

Abstract

Perioperative myocardial infarction (PMI) is one of the most important predictors of short- and long-term morbidity and mortality associated with non-cardiac surgery. Prevention of a PMI is thus a prerequisite for an improvement in overall postoperative outcome. The aetiology of PMI is multifactorial. The perioperative period induces large, unpredictable and unphysiological alterations in coronary plaque morphology, function and progression, and may trigger a mismatch of myocardial oxygen supply and demand. With many diverse factors involved, it is unlikely that one single intervention will successfully improve cardiac outcome following non-cardiac surgery. A multifactorial, step-wise approach is indicated. Based on increasing knowledge of the nature of atherosclerotic coronary artery disease, and in view of the poor positive predictive value of non-invasive cardiac stress tests, and the considerable risk of coronary angiography and coronary revascularization in high-risk patients, the paradigm is shifting from an emphasis on extensive non-invasive preoperative risk stratification to a combination of selective non-invasive testing and aggressive pharmacological perioperative therapy. Perioperative plaque stabilization by pharmacological means may be as important in the prevention of PMI as an increase in myocardial oxygen supply or a reduction in myocardial oxygen demand.

Myocardial ischemia-reperfusion and cardioprotection: a study with microdialysis in a porcine model

“…Reported incidence varies depending on the surgical setting and the presence of preoperative risk-factors in the selected group of patients, the methods of detecting myocardial ischemia, and the dynamically changing definitions and diagnostic criteria for myocardial infarction (Priebe 2004, Priebe 2005. In noncardiac surgery, some of the identified preoperative risk factors for perioperative cardiac complications including myocardial infarction are: high-risk surgery (major vascular, intraperitoneal, intrathoracic), ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin therapy and high serum creatinine (Lee 1999).…”

“…Furthermore, the duration of ischemic perioperative ECG changes correlates to cardiac troponin I release (Landesberg 2001). Perioperative myocardial infarction (PMI) is associated with increased short-and long-term mortality (Priebe 2005). Most patients surviving perioperative myocardial infarctions have angiographically extensive CAD (Priebe 2005).…”

“…Perioperative myocardial infarction (PMI) is associated with increased short-and long-term mortality (Priebe 2005). Most patients surviving perioperative myocardial infarctions have angiographically extensive CAD (Priebe 2005). Some cases of PMI seem to be caused by plaque haemorrhage, rupture, and thrombus formation (Priebe 2004, Priebe 2005.…”

“…Most patients surviving perioperative myocardial infarctions have angiographically extensive CAD (Priebe 2005). Some cases of PMI seem to be caused by plaque haemorrhage, rupture, and thrombus formation (Priebe 2004, Priebe 2005. However, PMI is mostly of the non-Q-wave type, preceded by ST-segment depressions, and may be associated with episodes of tachycardia (Landesberg 2001, 2 Landesberg 2003, Priebe 2004, Priebe 2005.…”

Infarto agudo do miocárdio após operações não cardíacas

“…In addition, the following occur: increased levels of procoagulant substances (fibrinogen and von Willebrand factor); reduced levels of anticoagulant factors (protein C, antithrombin III and alpha-2-macroglobulin); and increased platelet aggregation 1 . The increases in surgery-induced procoagulant and antifibrinolytic activities can trigger coronary thrombosis in patients with CAD and reduced coronary flow velocity, even in the absence of plaque rupture 57 .…”