A very important topic that every cardiologist should be aware of

1. Dr. Vijay Yadav
DM Cardiology-1st Year
IOM, MCVTC
PERIOPERATIVE
MYOCARDIAL
INFARCTION OR INJURY
AFTER NONCARDIAC
SURGERY

2. Procedure Related Cardiac Risk
High (5% mortality) Intermediate (1-5%
mortality)
Low (<1% mortality)
Emergent major OT Carotid endarterectomy Endoscopic procedures
Aortic & other vascular
surgeries
Head & Neck surgery Breast surgery
Peripheral vascular surgery Intraperitoneal Cataract surgery
Anticipated prolonged
surgery
Intrathoracic Dental surgery
Orthopedic surgery
Prostate surgery
Renal/Liver/Lung
transplantation
J Am Coll Cardiol. 2002;39(3):542.

3. Clinical Predictors of Increased Perioperative
Cardiovascular Risk (Myocardial Infarction, Heart
Failure, Death)
Major Intermediate Minor
ACS (7-30 days) Prior MI (> 30 days) Prior stroke
Arrhythmia
a. High grade AV block
b. VA with heart disease
c. SVT with FVR
DM Abnormal ECG
a. LVH
b. LBBB
c. ST-T changes
ADHF Renal Failure Uncontrolled HTN
MS/AS Compensated HF Advanced age
Atrial Fibrillation
J Am Coll Cardiol. 2002;39(3):542.

4. Functional Capacity (FC)
METS ACTIVITIES
1 METS Take care of self, such as eat, dress, or use the toilet
Walk indoors around a house
4 METS Walk up a flight of steps or a hill or walk on level ground at 3 to 4 mph
4-10 METS Scrubbing floors
Lifting or moving heavy furniture
Climb two flights of stairs
> 10 METS Swimming
Singles tennis
Football
Basketball
Skiing
Functional status can be expressed in metabolic equivalents
1 MET is defined as 3.5 mL O2 uptake/kg per min, which is the resting oxygen uptake in
a sitting position
The ability to achieve 4 METs of activity without symptoms is thought to be a good
prognostic indicator.
Circulation. 2014;130(24):e278.

5. Circulation. 1999;100(10):1043.

6. CARDIOVASCULAR RISK INDEX
(CVRI)
Age ≥75 years
History of heart disease
Angina or dyspnea
Hemoglobin <12 mg/dL
Vascular surgery
Emergency surgery
Additional validation
studies are
needed before this new
risk model can be
recommended.

7. MYOCARDIAL INJURY
 Myocardial injury is defined in the Fourth Universal Definition when
there is evidence of elevated cardiac troponin values with at least
one value above the 99th percentile upper reference limit.
 The myocardial injury is considered acute if there is a rise and/or fall
of cardiac troponin values.
 Clinical manifestations do not have to be present.
Myocardial Infarction

8. With the aging population, the number of adults undergoing non-cardiac
operations and the proportion at risk of peri-operative cardiovascular
complications are increasing each year.
Among patients aged 45 years or older undergoing major non-cardiac
surgery, more than 1% die in hospital or within 30 days of surgery.
Frequently patients are found to have elevated troponin levels after non-
cardiac surgery.
This perioperative myocardial injury as determined by isolated troponin
elevation is not synonymous with myocardial infarction.
Perioperative Myocardial Injury is a common complication after non-
cardiac surgery.
Associated with substantial short- and long-term mortality despite early
detection during routine clinical screening.

9. Myocardial Injury after Non-cardiac
Surgery (MINS)
 MINS is defined as myocardial cell injury during the first
30 days after non-cardiac surgery due to an ischemic
etiology, i.e. no evidence of non-ischemic etiology:
 Sepsis
 Rapid AF
 Pulmonary Embolism
 Cardioversion
 Independently associated with mortality
 MINS includes:
 1. MI (both symptomatic and non-symptomatic)
 2.Postoperative elevations in troponin without symptoms,
electrocardiographic abnormalities, or other criteria that meet the
universal definition and have no evidence of a nonischemic etiology for
troponin elevation

10. • In contrast with spontaneous myocardial infarction (MI), PMI most
commonly does not exhibit typical symptoms of myocardial
ischemia, such as chest pain, angina pectoris, or dyspnea, and is
therefore missed in routine clinical practice.
• Analgesics can mask cardiac ischemic symptoms during first 48
hours after surgery when most MIs occur.
• Also ECGs are ordered after detection of an elevated troponin,
which may be 12-24 hours after the event.
• Perioperative myocardial infarction (MI) after noncardiac surgery
occurs commonly and as many as 1 in 10 of those who suffer a
perioperative MI die within 30 days after surgery.

11. MECHANISM
Supply-demand mismatch:
• Rise in catecholamine concentrations
• Increase HR, BP, free fatty acid concentrations
Plaque rupture
Acute thrombotic lesions
• Non-cardiac surgery is associated with platelet activation
Fibroatheroma

12.  Non-high sensitivity cTn
assay was measured during first
3 days postoperative days
 93% had ischemic etiology
 MINS: 8%
• 41.8%: MI as per universal
definition
 High-sensitivity cTn asaay
was was measured during first 3
days postoperative days
 MINS: 17.9%
• 21.7% MI as per universal
definition
1st VISION Cohort of 15,065 2nd VISION Cohort of 21,842

13. 0% 10% 20% 30% 40% 50% 60% 70% 80%
CAD
Prior MI
Chronic HF
AF
VHD
PAD
Prior Stroke
HTN
DM

14. • Perioperative Myocardial Injury: 16%
• Typical chest pain: 6%
• Any Ischemic symptom: 18%
• 29% had any of the following:
▫ Ischemic symptom
▫ ECG changes
▫ Loss of myocardial viability on imaging

15. Incidence of MI: 5 % in 30 days
74% of these MI occurred within 48 hours
65% had no ischemic symptoms
30 day mortality of perioperative asymptomatic MI = Symptomatic M
POISE Trial
19 APRIL 2011

17. 19 APRIL 2011

18. Major bleeding: 0.8%
Q wave MI: 0.24%
(Hemorrhage was independently associated with MI
[HR] 2.7,95% CI 2.1-3.4)

19. Anesthetic/Analgesic/Amnes
tic agents
Muted symptoms
OR
Atypical symptoms
CLINICAL FEATURES

20. Refers to the perioperative measurement of
troponin and procurement of an ECG in the
perioperative period in patients who have no
symptoms or signs of myocardial ischemia but
who are at relatively high risk.

21. Troponin
• Recommended for screening of perioperative MINS in
patients at high risk for a perioperative myocardial
infarction.
• A highly sensitive troponin (hs-cTn) should be obtained at 6
to 12 hours and on days one, two, and three after
surgery.
• Identifies patients with MINS – no ischemic symptoms &
normal ECG.
• Preventive therapies with Aspirin and Statin can be
commenced after prompt evaluation, that might not otherwise
be done.

22. Assessment of cardiac troponin in high risk patients both before
and 48 to 72 hours after major surgery

25. Symptoms of myocardial ischemia: Recommended
Asymptomatic but at high cardiac risk for perioperative
MI: Baseline, Day 1, Day 2, and Day 3

26. PROGNOSIS
Short- and long-term mortality are significantly
increased in patients with a perioperative increase in
cardiac troponin irrespective of whether they are
labelled as having myocardial infarction or myocardial
injury after noncardiac surgery (MINS)
In hospital mortality : 5 – 25%

27. 30 day mortality: 1.2%
An absolute change of 5 ng/L across any two perioperative
measurements of high sensitivity cTn was independently
associated with an increase in 30-day mortality

28. Anesthesiology. 2011;114(4):796.

30. Vascular surgery, bleeding, and renal insufficiency were major predictors of long-
term mortality

31.  Aspirin: 81 to 325 mg followed by 75 to 100 mg daily
 Atorvastatin: 80 mg (40mg in patients who cannot receive
80mg daily) followed by same daily dose
 Aspirin and statin use are associated with a reduction in the
risk of 30 day mortality.
 Dabigatran 110 mg twice a day for 2 years. (MANAGETRIAL)

33. Major cardiac event free survival Aspirin, Statin
B-blocker, ACEi
Primary outcome at 12 months:
Death, MI, Pulmonary edema
Coronary revascularization
Hazard Ratio
MINS without IT 1.77
MINS with IT 0.63
Anesth Analg. 2014;119(5):1053.

34. • Myocardial injury after non-cardiac surgery (MINS) includes
myocardial infarction and isolated ischaemic troponin elevation
occurring within 30 days after surgery.
• It does not include perioperative myocardial injury due to non-
ischaemic causes (sepsis, rapid atrial fibrillation, pulmonary embolism,
and chronically elevated troponin measurement)
• Without routine perioperative troponin measurements, more than 80%
of MINS events would go unrecognized, because these patients do not
have ischemic symptoms.
• Both symptomatic and asymptomatic perioperative myocardial
infarctions are associated with a four times increased risk of 30-day
mortality.
• Treatment with Aspirin, Statin, and Dabigatran is recommended.
• Secondary prevention with aspirin, statin, ACEi, and Beta-blocker has a
mortality benefit.
TAKE HOME MESSAGE

35. THANK YOU