Myocardial injury is common after noncardiac surgery: AHA

Reuters Health - 12/10/2021 - Myocardial injury in noncardiac surgery (MINS) occurs in roughly one in five patients and while it may be symptomless, it triggers elevated troponin levels and increases postoperative risks of cardiovascular events and death, according to a new American Heart Association (AHA) scientific statement.

MINS is defined by elevated postoperative cardiac troponin concentrations that exceed the 99th percentile of the upper reference limit of the assay, attributable to a presumed ischemic mechanism with or without concomitant symptoms or signs.

Clinical symptoms may be masked by sedation or analgesia in the perioperative setting, so an ischemic feature (e.g., ischemic symptoms, electrocardiographic changes) is not required for a diagnosis.

The AHA scientific statement, published in Circulation, addresses the diagnosis and management of MINS, which affects about 20% of patients who undergo noncardiac surgery.

"The most essential message is that clinicians should take MINS seriously, as MINS is common, silent and deadly," Dr. Kurt Ruetzler of Cleveland Clinic in Ohio, who chaired the scientific statement writing group, told Reuters Health by email.

Other important points include the following, according to Dr. Ruetzler:

- Troponin screening should be performed for two-to-three days after surgery. "With this strategy," he said, "about 96% of MINS can be diagnosed."

- Patients diagnosed with MINS are at higher risk for short- and long-term mortality, he noted. "It is therefore essential to consider secondary cardiovascular prophylaxis using statins and lifestyle changes like smoking cessation or weight management. Statins make intuitive sense, given the high prevalence of arteriosclerotic disease in patients with MINS and the known benefits of statins in high-risk patients with vascular disease."

- "Antithrombotic therapy with aspirin appears to be beneficial," he said. "Anticoagulation with dabigatran was proven to be beneficial in reducing major vascular events by 28 %."

According to the statement, MINS is more likely to occur in people with preexisting cardiovascular risk factors, including older age (especially in those over 75); male sex; high blood pressure; type 2 diabetes; congestive heart failure; anemia; and obstructive sleep apnea.

Further, patients undergoing urgent or emergency procedures experienced a 2- to 3-fold higher adjusted odds of MINS. Several surgery types are associated with higher risks of MINS, including vascular procedures (especially open aortic or infrainguinal surgery) and intra-abdominal general surgical procedures.

Dr. Kaleigh Evans, a cardiologist at Northwestern Medicine Central DuPage Hospital in Chicago, commented in an email to Reuters Health, "The statement sheds light on a grey area of heart disease, using new information since the last guidelines were released. The screening (recommendation) adds clarity to the process of identifying which patients should be evaluated MINS and gives clear definitions for diagnosing the condition."

"Patients at high risk for MINS ideally should be evaluated by their primary care physician or cardiologist to ensure they are being appropriately treated for any current heart conditions and to ensure the lowest risk possible of cardiac complications before undergoing a planned surgery," she added. "It is better to prevent a potential event, especially as the optimal treatment for MINS is still being studied."

SOURCE: https://bit.ly/3auD3Q2 and https://bit.ly/3lBK3kN Circulation, online October 4, 2021.

By Marilynn Larkin



Posted on 12 October 202119 October 2021