Top Things to Know: Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery
Published: October 04, 2021
Prepared by Johanna A. Sharp, MSN, RN, Science and Medicine Advisor
- This scientific statement offers a clinical perspective of myocardial injury after non-cardiac surgery (MINS), which discusses the definition, epidemiology, pathophysiology, prognosis, and management of MINS, and future directions for research.
- Perioperative mortality after non-cardiac surgery is approximately 1-2% among inpatients age ≥45 years. Approximately half of these deaths are attributed to cardiovascular complications of surgery.
- MINS is an important clinical diagnosis which this manuscript defines an elevation of cardiac troponin after non-cardiac surgery, with or without ischemic symptoms or electrocardiographic abnormalities, after the exclusion of alternate non-ischemic causes of troponin elevation.
- Pre-operative cardiovascular risk assessment may identify patients with an increased likelihood to develop MINS. Estimates of perioperative risk can support perioperative management and provide data for use during informed consent for surgery and anesthesia.
- Several factors influence the incidence reporting of MINS. As the definition of MINS has not been consistent, troponin surveillance is not standard, and the incidence may vary according to age, sex, renal function, and urgency of the surgical procedure.
- It is suggested that patients ≥65 years of age or with known atherosclerotic disease have serial troponin measurements during the first 48 hours after surgery, while in the hospital. Troponin surveillance may prevent a missed MINS and provides an opportunity to initiate secondary prophylactic measures and appropriate follow-up.
- Myocardial injury is a more recent concept, and, to date, no published large multicenter randomized trial has used MINS as a primary endpoint; however, large ongoing perioperative trials include MINS in the primary outcome.
- Management of patients with MINS should be tailored to the suspected etiology of myocardial injury. Although myocardial injury is related to atherosclerotic cardiovascular disease, alternative etiologies of myocardial injury must be considered. This statement includes a suggested conceptual algorithm for the management of MINS.
- For the future, translational research is needed to determine the mechanism of MINS. Interdisciplinary research efforts will be critical to establish an advanced understanding of the pathophysiology of MINS.
- MINS was first described in 2014 and is a relatively new clinical diagnosis with clinically relevant questions regarding pathophysiology, pre-operative risk stratification, and post-operative management. Efforts to improve recognition and understanding of MINS will ultimately improve post-operative outcomes after non-cardiac surgery.
Citation
Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN; on behalf of the American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Clinical Cardiology; and Council on Cardiovascular Surgery and Anesthesia. Diagnosis and management of patients with myocardial injury after noncardiac surgery: a scientific statement from the American Heart Association [published online ahead of print October 4, 2021]. Circulation. doi: 10.1161/CIR.0000000000001024