Perioperative myocardial ischemia in patients undergoing noncardiac surgery—I: Incidence and severity during the 4 Day perioperative period

Abstract

To determine the incidence and characteristics of perioperative myocardial ischemia, the electrocardiographic (ECG) changes consistent with ischemia during the 4 day perioperative period were documented and characterized in 100 patients with or at risk for coronary artery disease undergoing noncardiac surgery. Using continuous two channel ECG monitoring (leads CC5 and CM5), the frequency and severity of ECG ischemic episodes defined by ST segment depression greater than or equal to 1 mm or elevation greater than or equal to 2 mm during the preoperative (up to 2 days), intraoperative and early postoperative (first 2 days) periods were compared. Preoperatively, 28 patients (28%) exhibited 105 episodes of ischemia; intraoperatively, 27 patients exhibited 39 episodes and postoperatively, 42 patients exhibited 187 episodes. There was no difference between the pre- and intraoperative episode characteristics. However, postoperative ischemic episodes were the most severe. The mean ST change was 1.5, 2 and 2.6 mm for pre-, intra- and postoperative episodes, respectively (p less than 0.0001 postoperative versus pre- or intraoperative); duration of ischemic episodes was 69, 45 and 207 min, respectively (p less than 0.005 postoperative versus preoperative, p less than 0.001 versus intraoperative) and area under the ST curve was 88, 74 and 383 mm.min (p less than 0.009 postoperative versus preoperative, p less than 0.005 versus intraoperative). Ninety-four percent of all postoperative ischemic episodes were silent; 80% of all episodes occurred without acute change (+/- 20% of control) in heart rate and 77% of intraoperative episodes occurred without acute change in blood pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Associations Between Cardiac Troponin, Mechanism of Myocardial Injury, and Long‐Term Mortality After Noncardiac Vascular Surgery

“…It is plausible that baseline cTnT elevation is likely more of a representation of underlying comorbidities than myocardial ischemia 21. That said, studies of preoperative Holter monitoring demonstrate that up to 27% of adults have reversible ST‐segment changes in the 2 days before surgery, suggestive that some perioperative cTnT elevation is indeed attributable to acute ischemia rather than chronic cTnT elevations 22, 23. Strategies to reduce mortality in this patient population deserve further study, and should extend beyond the perioperative space 24…”

Infarto agudo do miocárdio após operações não cardíacas

“…The incidence of perioperative AMI in low-risk patients with no history of CAD ranges from 0.3% to 3%, but can reach 33% in highrisk patients with history of CAD 9,55,64 . That large variation in the incidence of perioperative AMI can be explained not only by the type of the population assessed and the surgery performed 65 , but also by the lack of uniformity in the diagnostic criteria adopted by the studies.…”

STAR VaS - Short Term Atorvastatin Regime for Vasculopathic Subjects: a randomized placebo-controlled trial evaluating perioperative atorvastatin therapy in noncardiac surgery

“…Evidence, however, suggests that coronary artery thrombosis is as important a mechanism in perioperative myocardial infarctions as it is in nonoperative cardiac events. [3][4][5][6][7][8] Inflammation may have a crucial role in coronary thrombosis as elevated levels of various inflammatory markers, particularly C-reactive protein (CRP), are associated with an increased probability of adverse cardiovascular events. 9 As the inflammatory changes in nonoperative cardiac events are indistinguishable from the inflammatory changes that occur post surgery, it is possible that inflammation contributes to perioperative cardiac complications.…”