Suboptimal Outcome of Myocardial Infarction After Noncardiac Surgery
Physicians Can and Should Do More
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- hydroxymethylglutaryl-CoA reductase inhibitors
- myocardial infarction
Article, see p 2332
Among the 100 million adults worldwide ≥45 years of age who undergo major noncardiac surgery annually, it is estimated that 3 million will suffer a perioperative myocardial infarction (MI).1 Of these patients who will have an MI after noncardiac surgery, one third will experience an ischemic symptom, but two thirds will not experience an ischemic symptom.2 A proposed explanation for these asymptomatic events is that >70% of perioperative MIs occur within the first 48 hours after noncardiac surgery, a period when most patients receive analgesic medications that can mask ischemic symptoms.2
Based on a recent study by Smilowitz and colleagues3 that used administrative data from a 20% stratified sample of all US hospitals, in 2013, ≈40 000 Americans were diagnosed with an MI while in the hospital after noncardiac surgery. This figure is an underestimation of the true incidence because it is uncommon that surgeons routinely obtain perioperative troponin measurements in at-risk patients undergoing noncardiac surgery. Consequently, 65% of the perioperative MIs were likely missed because these patients would not have experienced an ischemic symptom that would have prompted surgeons to order troponin measurements. Therefore, in the United States, it is likely that 120 000 adults have an MI after noncardiac surgery every year.
Myocardial injury after noncardiac surgery (MINS) is more inclusive of individuals at risk who may benefit from additional surveillance and includes (1) MI based on the universal definition of MI (ie, an elevated troponin measurement with ≥1 ischemic features, such as an ischemic ECG finding),4 and (2) isolated ischemic troponin elevation (ie, a troponin elevation after surgery with no alternative nonischemic explanation [eg, sepsis, rapid atrial fibrillation, pulmonary embolism, chronic troponin elevation] for myocardial injury), occurring in ≤30 days after surgery.5 MI accounts for 22% to 29% of …