Daniel I. Sessler | Department of Outcomes Research, Cleveland Clinic, United States
About 250 million patients worldwide have non-cardiac surgery each year, and roughly 3 million die within a month of surgery. Postoperative myocardial infarctions occur in 8% of surgical inpatients over the age of 45 years.1 The 30-day mortality is a remarkable 10%.2 This makes postoperative infarctions by far the leading cause of unexpected death within a month after otherwise routine non-cardiac surgery.
Predicting postoperative myocardial infarctions remains challenging. The best pre-operative predictor appears to be NTproBNP,3,4 but no predictor is sufficiently accurate for individual patients. Recent research has thus focused on prevention. Major trials, each with 7,000-10,000 randomized patients, show that beta blockers,5 aspirin,6 clonidine,7 and avoiding nitrous oxide8 do not safely prevent infarctions. There is, however, a strong association between intraoperative hypotension and postoperative infarctions.9
How best to treat postoperative infarctions remains unclear, but multiple interventions are likely to prevent re-infarctions including aspirin, statins, angiotensin converting enzyme inhibitors, hypertension control, smoking cessation, improved diet, and exercise.
About 80% of postoperative myocardial infarctions are clinically silent, but, mortality is identical for silent and clinically apparent infarctions. Detecting clinically silent infarctions is thus critical. Troponin screening is currently the only reliable way to assess silent infarctions and is now recommended by the American Heart Association for moderate–high-risk patients. Troponin screening should be routine in moderate-to-high risk surgical inpatients (i.e., first, second, and third postoperative mornings while patients remain hospitalized).
Chief Editor’s note: This is a short summary of Dr. D. Sessler’s lecture to be presented in the framework of the next Euroanaesthesia Congress, London, May 2016.
1 The Vascular Events In Noncardiac Surgery Patients Cohort Evaluation. JAMA 2012;307(21):2295-304.
2 Botto F, Alonso-Coello P, Chan MT, et al. Anesthesiology 2014;120(3):564-78.
3. Rodseth RN, Biccard BM, Chu R, et al. Anesthesiology 2013;119(2):270-83.