Causes and prevention of postoperative myocardial injury

Laura Verbree-Willemsen, Remco B Grobben, Judith Ar van Waes, Linda M Peelen, Hendrik M Nathoe, Wilton A van Klei, Diederick E Grobbee, Laura Verbree-Willemsen, Remco B Grobben, Judith Ar van Waes, Linda M Peelen, Hendrik M Nathoe, Wilton A van Klei, Diederick E Grobbee

Abstract

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.

Keywords: Postoperative period; aetiology; myocardial ischaemia; prevention and control; troponin.

Figures

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

References

    1. 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: 627–634.
    1. Devereaux PJ, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med 2011; 154: 523–528.
    1. Landesberg G, Beattie WS, Mosseri M, et al. Perioperative myocardial infarction. Circulation 2009; 119: 2936–2944.
    1. Landesberg G, Shatz V, Akopnik I, et al. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol 2003; 42: 1547–1554.
    1. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: the Joint Task Force on Non-cardiac Surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesth. Eur Hear J 2014; 35: 2383–2431.
    1. Devereaux PJ, Chan MT, Alonso-Coello P, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2012; 307: 2295–2304.
    1. van Waes JAR, Nathoe HM, de Graaff JC, et al. Myocardial injury after noncardiac surgery and its association with short-term mortality. Circulation 2013; 127: 2264–2271.
    1. Levy M, Heels-Ansdell D, Hiralal R, et al. Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery: a systematic review and meta-analysis. Anesthesiology 2011; 114: 796–806.
    1. Oscarsson A, Eintrei C, Anskar S, et al. Troponin T-values provide long-term prognosis in elderly patients undergoing non-cardiac surgery. Acta Anaesthesiol Scand 2004; 48: 1071–1079.
    1. Oberweis BS, Smilowitz NR, Nukala S, et al. Relation of perioperative elevation of troponin to long-term mortality after orthopedic surgery. Am J Cardiol 2015; 115: 1643–1648.
    1. van Waes JAR, Grobben RB, Nathoe HM, et al. One-year mortality, causes of death, and cardiac interventions in patients with postoperative myocardial injury. Anesth Analg 2016; 123: 29–37.
    1. Beattie WS, Karkouti K, Tait G, et al. Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery: a single-centre cohort study in 51,701 consecutive patients. Can J Anaesth 2012; 59: 1013–1022.
    1. Devereaux PJ, Biccard BM, Sigamani A, et al. Association of postoperative high-sensitivity troponin levels with myocardial injury and 30-day mortality among patients undergoing noncardiac surgery. JAMA 2017; 317: 1642–1642.
    1. Ekeloef S, Alamili M, Devereaux PJ, et al. Troponin elevations after non-cardiac, non-vascular surgery are predictive of major adverse cardiac events and mortality: a systematic review and meta-analysis. Br J Anaesth 2016; 117: 559–568.
    1. Nathoe HM, van Klei WA, Beattie WS. Perioperative troponin elevation: always myocardial injury, but not always myocardial infarction. Anesth Analg 2014; 119: 1014–1016.
    1. Horr S, Reed G, Menon V. Troponin elevation after noncardiac surgery: significance and management. Cleve Clin J Med 2015; 82: 595–602.
    1. Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014; 120: 564–578.
    1. Beckman JA. Postoperative troponin screening a cardiac cassandra? Circulation 2013; 127: 2253–2256.
    1. Devereaux PJ, Sessler DI. Cardiac complications in patients undergoing major noncardiac surgery. N Engl J Med 2015; 373: 2258–2269.
    1. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol 2012; 60: 1581–1598.
    1. Sheth T, Chan M, Butler C, et al. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ 2015; 350: h1907–h1907.
    1. Gimenez MR, Twerenbold R, Reichlin T, et al. Direct comparison of high-sensitivity-cardiac troponin I vs. T for the early diagnosis of acutemyocardial infarction. Eur Hear J 2014; 35: 2303–2311.
    1. Thygesen K, Mair J, Giannitsis E, et al. How to use high-sensitivity cardiac troponins in acute cardiac care. Eur Hear J 2012; 33: 2252–2257.
    1. Brown JC, Samaha E, Rao S, et al. High-sensitivity cardiac troponin T improves the diagnosis of perioperative MI. Anesth Analg 2017; 125: 1455–1462.
    1. Gualandro DM, Campos CA, Calderaro D, et al. Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: frequent and dangerous. Atherosclerosis 2012; 222: 191–195.
    1. Grobben RB, van Klei WA, Grobbee DE, et al. The aetiology of myocardial injury after non-cardiac surgery. Neth Heart J 2013; 21: 380–388.
    1. Grobben RB, van Waes JA, Leiner T, et al. Unexpected cardiac CT findings in patients with postoperative myocardial injury. Anesth Analg 2018; 126: 1462–1468.
    1. Pizzi C, Xhyheri B, Costa GM, et al. Nonobstructive versus obstructive coronary artery disease in acute coronary syndrome: a meta-analysis. J Am Heart Assoc 2016; 5: 1–15.
    1. Kaski JC and Vitale C. Microvascular angina and systemic hypertension. E-Journal Cardiol Pract 2016; 14.
    1. van Klei WA, Grobbee DE, Grobben RB, et al. Detection and management of asymptomatic myocardial injury after noncardiac surgery. Eur J Prev Cardiol 2013; 20: 918–921.
    1. Sellers D, Srinivas C, Djaiani G. Cardiovascular complications after non-cardiac surgery. Anaesthesia 2018; 73: 34–42.
    1. Noordzij PG, van Geffen O, Dijkstra IM, et al. High-sensitive cardiac troponin T measurements in prediction of non-cardiac complications after major abdominal surgery. Br J Anaesth 2015; 114: 909–918.
    1. Landesberg G, Jaffe AS. ‘Paradox’ of troponin elevations after non-cardiac surgery. Br J Anaesth 2015; 114: 863–865.
    1. Mauermann E, Puelacher C, Buse GL. Myocardial injury after noncardiac surgery: an underappreciated problem and current challenges. Curr Opin Anaesthesiol 2016; 29: 403–412.
    1. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J 2014; 35: 3033–3080.
    1. Matthews JC, McLaughlin V. Acute right ventricular failure in the setting of acute pulmonary embolism or chronic pulmonary hypertension: a detailed review of the pathophysiology, diagnosis, and management. Curr Cardiol Rev 2008; 4: 49–59.
    1. Rohde LE, Polanczyk CA, Goldman L, et al. Usefulness of transthoracic echocardiography as a tool for risk stratification of patients undergoing major noncardiac surgery. Am J Cardiol 2001; 87: 505–509.
    1. Nagele P, Brown F, Gage BF, et al. High-sensitivity cardiac troponin T in prediction and diagnosis of myocardial infarction and long-term mortality after noncardiac surgery. Am Heart J 2013; 166: 325–332.
    1. Ryding A, Kumar S, Worthington AM, et al. Prognostic value of brain natriuretic peptide in noncardiac surgery: a meta-analysis. Anesthesiology 2009; 111: 311–319.
    1. Rodseth RN, Biccard BM, Le Manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery. J Am Coll Cardiol 2014; 63: 170–180.
    1. Maile MD, Jewell ES, Engoren MC. Timing of preoperative troponin elevations and postoperative mortality after noncardiac surgery. Anesth Analg 2016; 123: 135–140.
    1. Libby P. Inflammation in atherosclerosis. Nature 2002; 420: 868–874.
    1. Maiolino G, Bisogni V, Rossitto G, et al. Lipoprotein-associated phospholipase A2 prognostic role in atherosclerotic complications. World J Cardiol 2015; 7: 609–620.
    1. Chung H, Kwon HM, Kim J, et al. Lipoprotein-associated phospholipase A2 is related to plaque stability and is a potential biomarker for acute coronary syndrome. Yonsei Med J 2014; 55: 1507–1515.
    1. Liu YS, Hu XB, Li HZ, et al. Association of lipoprotein-associated phospholipase A(2) with characteristics of vulnerable coronary atherosclerotic plaques. Yonsei Med J 2011; 52: 914–922.
    1. Montalescot G, Sechtem U, Achenbach S, et al. 2013 ESC Guidelines on the management of stable coronary artery disease: the Task Force on the Management of Stable Coronary Artery Disease of the European Society of Cardiology. Eur Heart J 2013; 34: 2949–3003.
    1. Wijeysundera DN, Duncan D, Nkonde-Price C, et al. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 64: 2406–2425.
    1. Bouri S, Shun-Shin MJ, Cole GD, et al. Meta-analysis of secure randomised controlled trials of beta-blockade to prevent perioperative death in non-cardiac surgery. Heart 2014; 100: 456–464.
    1. Gorenek B, Pelliccia A, Benjamin EJ, et al. European Heart Rhythm Association (EHRA)/European Association of Cardiovascular Prevention and Rehabilitation (EACPR) position paper on how to prevent atrial fibrillation endorsed by the Heart Rhythm Society (HRS) and Asia Pacific Heart Rhythm Society (APHRS). Eur J Prev Cardiol 2017; 24: 4–40.
    1. Devereaux PJ, Mrkobrada M, Sessler DI, et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370: 1494–1503.
    1. Devereaux PJ, Sessler DI, Leslie K, et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med 2014; 370: 1504–1513.
    1. de Waal BA, Buise MP, van Zundert AAJ. Perioperative statin therapy in patients at high risk for cardiovascular morbidity undergoing surgery: a review. Br J Anaesth 2014; 114: 44–52.
    1. Berwanger O, Le MY, Suzumura EA, et al. Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. Eur Heart J 2016; 37: 177–185.
    1. Wang L, Peng P, Zhang O, et al. High-dose statin pretreatment decreases periprocedural myocardial infarction and cardiovascular events in patients undergoing elective percutaneous coronary intervention: a meta-analysis of twenty-four randomized controlled trials. PLoS One 2014; 9: 1–21.
    1. Xia J, Qu Y, Yin C, et al. Preoperative rosuvastatin protects patients with coronary artery disease undergoing noncardiac surgery. Cardiology 2015; 131: 30–37.
    1. Zou Z, Hb Y, Yang B, et al. Perioperative angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers for preventing mortality and morbidity in adults. Cochrane Database Syst Rev. Epub ahead of print 2016. DOI: 10.1002/14651858.CD009210.pub2. .
    1. Turan A, You J, Shiba A, et al. Angiotensin converting enzyme inhibitors are not associated with respiratory complications or mortality after noncardiac surgery. Anesth Analg 2012; 114: 552–560.
    1. Rosenman DJ, McDonald FS, Ebbert JO, et al. Clinical consequences of withholding versus administering renin–angiotensin–aldosterone system antagonists in the preoperative period. J Hosp Med 2008; 3: 319–325.
    1. Roshanov PS, Rochwerg B, Patel A, et al. Preoperative administration of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers. Anesthesiology 2017; 126: 1–3.
    1. Mcfalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2009; 351: 2795–2804.
    1. Illuminati G, Schneider F, Greco C, et al. Long-term results of a randomized controlled trial analyzing the role of systematic pre-operative coronary angiography before elective carotid endarterectomy in patients with asymptomatic coronary artery disease. Eur J Vasc Endovasc Surg 2015; 49: 366–374.
    1. Marmelo F, Rocha V, Gonçalves D. The impact of prehabilitation on post-surgical complications in patients undergoing non-urgent cardiovascular surgical intervention: systematic review and meta-analysis. Eur J Prev Cardiol 2018; 25: 404–417.
    1. Pouwels S, Hageman D, Gommans LNM, et al. Preoperative exercise therapy in surgical care: a scoping review. J Clin Anesth 2016; 33: 476–490.
    1. Tew GA, Ayyash R, Durrand J, et al. Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery. Anaesthesia 2018; 73: 750–768.
    1. Carson JL, Duff A, Poses RM, et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996; 348: 1055–1060.
    1. Chatterjee S, Wetterslev J, Sharma A, et al. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA Intern Med 2013; 173: 132–139.
    1. Valentijn TM, Hoeks SE, Martienus KA, et al. Impact of haemoglobin concentration on cardiovascular outcome after vascular surgery: a retrospective observational cohort study. Eur J Anaesthesiol 2013; 30: 664–670.
    1. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med 2011; 365: 2453–2462.
    1. Carson JL, Sieber F, Cook DR, et al. Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial. Lancet 2015; 385: 1183–1189.
    1. Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med 2012; 157: 49–58.
    1. van Waes JAR, van Klei WA, Wijeysundera DN, et al. Association between intraoperative hypotension and myocardial injury after vascular surgery. Anesthesiology 2016; 124: 35–44.
    1. Hallqvist L, Martensson J, Granath F, et al. Intraoperative hypotension is associated with myocardial damage in noncardiac surgery: an observational study. Eur J Anaesthesiol 2016; 33: 450–456.
    1. Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology 2013; 119: 507–515.
    1. Gillies MA, Shah ASV, Mullenheim J, et al. Perioperative myocardial injury in patients receiving cardiac output-guided haemodynamic therapy: a substudy of the OPTIMISE Trial. Br J Anaesth 2015; 115: 227–233.
    1. Foucrier A, Rodseth R, Aissaoui M, et al. The long-term impact of early cardiovascular therapy intensification for postoperative troponin elevation after major vascular surgery. Anesth Analg 2014; 119: 1053–1063.
    1. Chong CP, van Gaal WJ, Ryan JE, et al. Does cardiology intervention improve mortality for post-operative troponin elevations after emergency orthopaedic-geriatric surgery? A randomised controlled study. Injury 2012; 43: 1193–1198.

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