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Sumario Vol. 42 - Nº 1 Enero - Marzo 2013

Myocardial infarction after noncardiac surgery.
We have forgotten something?

Héctor Luciardi [1], Juan Muntaner [1], Fernando Botto [2].

[1] Centro Modelo de Cardiología. (CMC). Tucumán, Argentina.
[2] Instituto Cardiovascular de Buenos Aires (ICBA); Avenida del Libertador 6302. (1428) Buenos Aires, Argentina.
[2] Estudios Clínicos Latino América (ECLA); Madres de Plaza de Mayo 3020. Piso 10. Rosario (S2013SW).
E Mail

Recibido 15-ENE-2013 – ACEPTADO 12-FEBRERO-2013.

Opinion articles reflect the views of the authors,
not necessarily those of the Editorial Committee FAC.

Rev Fed Arg Cardiol. 2013; 42(1): 5-6


Print version Imprimir sólo la columna central

 

In spite of the benefit associated to the surgical treatment, the perioperative complications are frequent, including death. Every year, around 200 million patients undergo noncardiac surgeries in all the world, from which we can estimate that 10 millions present perioperative myocardial infarction (MI), during or after it [1]. Undoubtedly, between the greatest vascular complications (vascular death, MI, cardiac arrest and ictus), MI is the most frequent and is associated to mortality at 30 days equal or superior to MI fromanon-operative scenario.

The universal definition of MI [2] does not approach directly the diagnosis of myocardial infarction after noncardiac surgery. Devereaux PJ et al, have proposed a definition of perioperative MI in patients that undergo noncardiac surgery [3], which includes the elevation of a cardiac biomarker or enzymatic levels, and 1 or more of the following characteristics: ischemic symptoms, development of pathological Q waves in 2 adjacent ECG leads, ischemic changes detected in the ECG, coronary artery intervention, or tests consistent with MI in cardiac imaging studies.

According to a sub-analysis of the most important randomized study that has been done in this context (POISE Study), 65% of these patients do not experience ischemic symptoms, which prevents, or at least delays, a proper diagnosis. This and other studies of small dimensions have suggested that most of perioperative MI occur within the 48 hours of the surgery, and most present without ischemic symptoms [4,5].

Classically, perioperative MI has been considered as the result of an imbalance between oxygen input and demand. However, there is evidence from necropsies and angiographic studies that point out that at least half respond to an intracoronary thrombotic phenomenon, similar to the scenario of non-operative MI [6,7]. Perioperative MI differentiates in two aspects: its prognosis is worse, since the probability of dying within 30 days is almost twice as much, and paradoxically, the treatment indicated is less intensive [8]. According to these considerations, we can assume that the myocardial injury after noncardiac surgery is a significant and forgotten problem of public health.

The POISE (PeriOperative ISchemic Evaluation) study [9], which randomized 8,351 patients to receive metoprolol or placebo for 30 days, starting 2 or 4 hours before the surgery, had an incidence of 1.6% of death of vascular origin, 0.7% of stroke, 0.5% of non-fatal cardiac arrest, and 5.0% of MI in the first 30 days. 74% of MI occurred in the first 48 hours and 65.3% were asymptomatic. Besides, mortality was 11.6% at 30 days, which in more than half of the cases (58.3%) occurred within the first 48 hours, regardless of whether the patient presented ischemic symptoms or not [10].

On the other hand, Levy et al [11] carried out a meta-analysis of 10 studies (n=1,728 patients) that evaluated the independent prognostic value of mortality in the mid term (<12 months) of high levels of troponin after noncardiac surgery. The results showed an increase in risk of almost 7 times in the cases of high troponin (odds ratio of 6.7, CI 95% 4.1-10.9). However, the total number of patients included, and consequently the number of events were not enough to obtain conclusive results. Another limitation was that different troponin tests were used.

Recently, an international study of large dimensions (n=15,133), the VISION (Vascular Events in Noncardiac Surgery Patients Cohort Evaluation) study [12], evaluated the greatest complications after noncardiac surgery, and the significance of the measurement of troponin T (TnT). The peak value of TnT was the strongest predictor of death at 30 days (1.0% for a TnT value ≤0.01 ng/mL, 4.0% for a value of 0.02 ng/mL, 9.3% for a value of 0.03-0.29 ng/ml and 16.9% for a value of ≥0.30 ng/ml) and the analysis of the attributable population risk suggested that the TnT elevation could explain 41.8% of deaths.

Having in mind the specificity of troponin for myocardial tissue, the average time until death for a peak value of TnT of 0.02 ng/ml is 13.5 days and 9 days for a value of 0.03 ng/ml. These smaller values of TnT may already represent a warning of myocardial injury [13]. The greater the peak value of TnT, the briefer the average interval of time until death.

This evidence suggests the need of a routine monitoring of the presence of myocardial injury in the post-operative of patients in high risk, trying to detect subclinical MI, the prognosis of which is poor. A limitation of the first report of the VISION Study lies in that the increase in TnT was analyzed, without considering the ischemic etiology versus others (pulmonary embolism, sepsis, etc.); analysis that is currently being reviewed.

In an attempt to try to identify the patients that could suffer the complication of a perioperative MI, the investigators of the POISE study reported the independent predictors to bare in mind and highlighted a statistically significant association with age, stroke and prior renal failure, major vascular surgery, the character of emergency or urgency of a surgery, major postoperative bleeding and with each increase of 10 beats/minute in the pre-randomization heart rate [9]. However, the presurgical risk stratification is insufficient when postoperative troponin is included in the statistical models.

Finally, it is necessary to highlight the lack of evidence on the treatment of perioperative MI. The international multicenter MANAGE (Management of myocardial injury After NoncArdiac surGEry) study will be the first clinical randomized study in this context and will determine the impact of a direct inhibitor of thrombin (dabigatran) versus placebo, in those patients that suffered myocardial damage, added to aspirin, along with a partial factorial design that will evaluate the impact of omeprazole versus placebo in this condition.

To conclude, although the measurements of troponin after a non-cardiac surgery are not conducted as a routine, the simplicity of this test and its prognostic power when requested within the first 3 days of surgery, suggest it could have a significant clinical usefulness to improve risk stratification. Thus, the prognosis of the patients with high troponin could benefit from early interventions, pharmacological or mechanical, such as coronary angioplasty.

The third universal definition of myocardial infarction published in 2012 [14], added the recommendation of a routine monitoring of biomarkers in patients in high risk, before and 48-72 hours after major surgery, based on the evidence we have mentioned previously.

 

 

REFERENCES.

  1. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008; 372 (9633): 139-144.
  2. Thygesen K, Alpert JS, White HD, et al; Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Circulation 2007; 116: 2634-2653.
  3. Devereaux PJ, Goldman L, Yusuf S, et aL. Surveillance and prevention of major perioperative ischemic cardiac events in patients undergoing noncardiac surgery: a review. CMAJ 2005; 173: 779-788.
  4. Badner NH, Knill RL, Brown JE, et al. Myocardial infarction after noncardiac surgery. Anesthesiology 1998; 88: 572-578.
  5. Mangano DT, Browner WS, Hollenberg M, et al. Association of perioperative myocardial ischemia with cardiac morbidity and mortality in men undergoing noncardiac surgery. The Study of Perioperative Ischemia Research Group. N Engl J Med 1990; 323: 1781-1788.
  6. Devereaux PJ, Chan M, Eikelboom J. Major vascular complications in patients undergoing noncardiac surgery: The magnitude of the problem, risk prediction, surveillance, and prevention. In: Yusuf S, Cairns JA, Camm AJ, Fallen EL, Gersh BJ, editors. Evidence based Cardiology. 3rd ed. London, England: BMJ Books, 2009: 47-62.
  7. Gualandro D, Campos C, Calderaro D, et al. Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: Frequent and dangerous. Atherosclerosis 2012, 222 (1): 191-195.
  8. Devereaux PJ, Goldman L, Cook DJ, et al. Perioperative cardiac events in patients undergoing noncardiac surgery: a review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. CMAJ 2005; 173 (6): 627-634.
  9. Devereaux PJ, Yang H, Yusuf S, et al. POISE Study Group. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371: 1839-1847.
  10. Devereaux PJ, Xavier D, Pogue J, et al. Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery. Ann Intern Med. 2011; 154 (8): 523-528.
  11. Levy M, Heels-Ansdell D, Hiralal R, et al. Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery. Anesthesiology 2011; 114 (4): 796-806.
  12. The Vascular Events In Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators. Association Between Postoperative Troponin Levels and 30-Day Mortality Among. Patients Undergoing Noncardiac Surgery. JAMA 2012; 307 (21): 2295-2304.
  13. Jaffe AS, Ravkilde J, Roberts R, et al. It’s time for a change to a troponin standard. Circulation 2000; 102 (11): 1216-1220.
  14. Thygesen K, Alpert JS, Jaffe AS, et al. The Third Universal Definition of Myocardial Infarction. Circulation 2012; 126 (16): 2020-2035.

 

 

Publication: March 2013

 
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