Content area
Full text
Perioperative myocardial infarction (PMI) is a major cause of morbidity and mortality in patients undergoing noncardiac surgery. The incidence of PMI varies depending on the method used for diagnosis and is likely to increase as the population ages. Studies have examined different methods for prevention of myocardial infarction (MI), including the use of perioperative β-blockers, α^sub 2^-agonists, and statin therapy. However, few studies have focused on the treatment of PMI. Current therapy for acute MI generally involves anticoagulation and antiplatelet therapy, raising the potential for surgical site hemorrhage in this population. This article reviews the possible mechanisms, diagnosis, and treatment options for MI in the surgical setting. We also suggest algorithms for treatment. (CHEST 2006; 130:584-596)
Key words: anticoagulation; myocardial ischemia; noncardiac surgery; percutaneous coronary intervention; perioperative myocardial infarction; platelet inhibitors
Abbreviations: ACC = American College of Cardiology; ACE = angiotensin-converting enzyme; AHA = American Heart Association; CABG = coronary artery bypass grafting; CAD = coronary artery disease; CHF = congestive heart failure; CK-MB = creatinine kinase-MB; HMG-CoA = hydroxy-3-methylglutaryl coenzyme A; IABP = intra-aortic balloon pump; LMWH = low-molecular-weight heparin; MI = myocardial infarction; NSTEMI = non-ST-segment elevation myocardial infarction; PCI = percutaneous coronary intervention; PMI = perioperative myocardial infarction; STEMI = ST-segment elevation myocardial infarction; UFH = unfractionated heparin
Learning Objectives: 1. Understand what risk factors are useful in assessing risk for perioperative myocardial infarction. 2. Understand the diagnostic criteria for myocardial infarction and how those criteria may be altered in the perioperative setting. 3. Understand therapeutic options for perioperative myocardial infarction.
THE CLINICAL PROBLEM
Approximately 30 million surgeries are performed annually in the United States. One million of these patients have known coronary artery disease (CAD), and an additional 2 to 3 million are at risk for CAD. The patients with CAD and those at risk for CAD have higher rates of perioperative myocardial infarction (PMI), cardiac death, and other morbidity related to ischemic heart disease. Mortality from myocardial infarction (MI) after noncardiac surgery is believed to be 10 to 15%,1 similar to that in nonsurgical patients. This is in contrast to older studies2,3 that indicate higher mortality in postsurgical patients.
Many recent studies, reviews, and guidelines have focused on the prevention of myocardial ischemia and MI in the perioperative period,...