The aetiology of myocardial injury after non-cardiac surgery

Grobben, Remco B.; Klei, Wilton A. van; Grobbee, D. E.; Nathoe, Hendrik M.

doi:10.1007/s12471-013-0463-2

Cited by 19 publications

(11 citation statements)

References 55 publications

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“…29 However, the fact that obstructive CAD on CCTA was absent in 30-50% of patients with PMI in those two studies suggests that non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, also play a role in a significant proportion of patients with PMI ( Figure 1, right panel). 11,26,30,31 This notion was underlined by Noordzij and colleagues, who reported that non-cardiac complications such as respiratory insufficiency, sepsis and bleeding were associated with a postoperative troponin increase of over 100% compared to preoperative baseline measurements in patients at risk of CAD. 32 A potentially relevant factor in the recognition of the underlying pathology of PMI (and consecutive treatment) may lay in peak troponin concentrations.…”

Section: Detection Of Pmimentioning

confidence: 98%

“…3,19,26 In type II myocardial ischaemia, factors such as hyper or hypotension, tachycardia and anaemia result in a (more generalised) oxygen supply-demand mismatch (Figure 1, left panel). 3,19,26 Until recently, it was assumed that PMI mainly occurs in patients with CAD. However, this assumption was contradicted by a prospective cohort study in 955 non-cardiac surgery patients who underwent preoperative coronary computed tomographic angiography (CCTA), which showed that 20 of 71 postoperative myocardial infarctions (28%) occurred in patients without obstructive CAD.…”

Section: Detection Of Pmimentioning

confidence: 99%

“…1,3,17,25 Type I ischaemia is caused by acute coronary thrombosis due to rupture of a vulnerable plaque and can be triggered by perioperative factors such as inflammation, hypercoagulability and blood pressure fluctuations during surgery. 3,19,26 In type II myocardial ischaemia, factors such as hyper or hypotension, tachycardia and anaemia result in a (more generalised) oxygen supply–demand mismatch (Figure 1, left panel). 3,19,26

Figure 1.Different pathways leading to postoperative myocardial injury (PMI) including cardiac causes (left panel) and non-cardiac causes (right panel). …”

Section: Aetiologymentioning

confidence: 99%

“…3,19,26 In type II myocardial ischaemia, factors such as hyper or hypotension, tachycardia and anaemia result in a (more generalised) oxygen supply–demand mismatch (Figure 1, left panel). 3,19,26

Figure 1.Different pathways leading to postoperative myocardial injury (PMI) including cardiac causes (left panel) and non-cardiac causes (right panel). …”

Section: Aetiologymentioning

confidence: 99%

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Causes and prevention of postoperative myocardial injury

Verbree-Willemsen

Grobben

Waes

et al. 2019

European Journal of Preventive Cardiology

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Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation - or postoperative myocardial injury - can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation.

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Section: Detection Of Pmimentioning

confidence: 98%

Section: Detection Of Pmimentioning

confidence: 99%

Figure 1.Different pathways leading to postoperative myocardial injury (PMI) including cardiac causes (left panel) and non-cardiac causes (right panel). …”

Section: Aetiologymentioning

confidence: 99%

Figure 1.Different pathways leading to postoperative myocardial injury (PMI) including cardiac causes (left panel) and non-cardiac causes (right panel). …”

Section: Aetiologymentioning

confidence: 99%

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Causes and prevention of postoperative myocardial injury

Verbree-Willemsen

Grobben

Waes

et al. 2019

European Journal of Preventive Cardiology

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“…The proposed mechanisms of myocardial injury in the perioperative period are fissuring or rupture of atherosclerotic plaque, a hypercoagulable state, myocardial oxygen demandsupply mismatch due to hypotension, tachycardia, elevated catecholamine levels and dysrhythmias. (18) As such, in the prevention of MINS, a balance must be attained between providing adequate antithrombotic cover without increasing the risk of bleeding and minimising the adverse effects of the increased sympathetic drive while avoiding hypotension.…”

Section: Preventionmentioning

confidence: 99%

Myocardial injury in non-cardiac surgery: complexities and challenges

Kuthiah

2020

smedj

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The term MINS (myocardial injury after non-cardiac surgery) was coined to broadly describe perioperative troponin elevation that is deemed to be due to a cardiac cause. However, this term is commonly used in literature to represent cases that do not fulfil the criteria for the diagnosis of myocardial infarction. Asymptomatic troponin elevation that does not fulfil the criteria for acute coronary syndrome in the perioperative setting has been shown to be associated with increased mortality. The discovery of MINS presents new opportunities to improve outcomes for surgical patients. Unfortunately, awareness of MINS among practitioners remains low and implementation of perioperative troponin monitoring is poor. Given its significance, the detection, management and prevention of MINS should not be overlooked.

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Perioperative risk and mortality after major surgery

et al. 2015

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Although anesthesia-associated mortality has been significantly reduced down to 0.00068-0.00082% over the last decades, recent studies have revealed a high perioperative mortality of 0.8- 4%. Apart from anesthesia and surgery-induced major complications, perioperative mortality is primarily negatively influenced by individual patient comorbidities. These risk factors predispose for acute critical incidents (e.g., myocardial infarction); however, the majority of fatal complications are a result of slowly progressing conditions, particularly infections or the sequelae of systemic inflammation. This implicates a broad window of opportunity for the detection and treatment of slow-onset complications to improve the perioperative outcome. The term "failure to rescue" (FTR), i.e., the proportion of patients who die from major complications compared to the number of all patients with complications, has been introduced as a valid indicator for the quality of perioperative care. Growing evidence has already shown that FTR is an underestimated factor in perioperative medicine accounting for or at least being involved in the development of postoperative mortality. While the incidence of severe postoperative complications amazingly does not show much variation between hospitals, FTR shows significant differences implying a major potential for improvement. With 14 million surgical procedures per year in Germany, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40% mean that there are an estimated 60,000 preventable deaths per year. Hence, in the future it will be imperative to (1) identify patients at risk, (2) to prevent the development of postoperative complications with the use of adequate adjunctive therapeutic strategies, (3) to establish surveillance and monitoring systems for the early detection of postoperative complications and (4) to treat postoperative complications efficiently and in time when they arise.

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The aetiology of myocardial injury after non-cardiac surgery

Cited by 19 publications

References 55 publications

Causes and prevention of postoperative myocardial injury

Causes and prevention of postoperative myocardial injury

Myocardial injury in non-cardiac surgery: complexities and challenges

Perioperative risk and mortality after major surgery

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