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2006, Number S1

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Rev Mex Anest 2006; 29 (S1)

Myocardial ischemia and postoperative management

Ellis JE

Language: English
References: 51
Page: 62-66
PDF size: 78.46 Kb.


Text Extraction

Tremendous morbidity remains associated with coronary artery disease (CAD) in surgical patients. Perioperative myocardial infarction is still often lethal and may compromise a patient’s functional status after surgery. Patients who suffer postoperative myocardial infarction may on average incur $10,000 - $20,000 in additional hospital costs compared to similar patients who do not suffer myocardial infarction. Attempts to improve perioperative outcome of patients at risk for having CAD have focused on 3 approaches: (i) preoperative identification of high-risk patients who might benefit from myocardial revascularization, (ii) improved detection of perioperative myocardial ischemia to allow for prompt therapeutic intervention, and (iii) the prophylactic use of anesthetic and antiischemic techniques to decrease the prevalence and severity of postoperative myocardial ischemia. This lecture will address the last two approaches after reviewing the pathophysiology, demographics, and prognosis of postoperative myocardial ischemia and infarction in patients undergoing noncardiac surgery. Many of studies referenced have been undertaken in vascular surgery patients.


REFERENCES

  1. Armanious S, Wong DT, Etchells E, Higgins P, Chung F. Successful implementation of perioperative beta-blockade utilizing a multidisciplinary approach. Can J Anaesth 2003;50:131-6.

  2. Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in noncardiac surgery:scientific review. JAMA 2002;287:1435-44.

  3. Boersma E, Poldermans D, Bax JJ, Steyerberg EW, Thomson IR, Banga JD, van De Ven LL, van Urk H, Roelandt JR. Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA 2001;285:1865-73. (defines which patients most likely to benefit from beta blockade)

  4. Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000;355:773-8. Review.

  5. Charlson ME, MacKenzie CR, Ales K, Gold JP, Fairclough G Jr, Shires GT. Surveillance for postoperative myocardial infarction after noncardiac operations. Surg Gynecol Obstet 1988;167:407- 14. (defines which patients on clinical criteria likely to rule-in for MI; suggested “rule-out” algorithm)

  6. Durazzo AE, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leao P, Caramelli B. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized triRevista Mexicana de Anestesiología Ellis JE. Myocardial ischemia and postoperative management MG S66 al. J Vasc Surg 2004;39:967-75. (statins started roughly a month before vascular surgery and continued until 2 weeks after surgery reduced cardiac events)

  7. Ellis JE, Drijvers G, Pedlow S, Laff SP, Sorrentino MJ, Foss JF, Shah M, Busse JR, Mantha S, McKinsey JF, et al. Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis. Anesth Analg 1994;79:1133-40. (clondine premedication reduces heart rate and intraoperative myocardial ischemia)

  8. Fleisher LA, Eagle KA. Lowering Cardiac Risk in Noncardiac Surgery. N Engl J Med 2001;345:1677-1682. (succinct, evidence-based review)

  9. Frank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly S, Beattie C. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997;277:1127-34. (forced air warming reduces cardiac complications)

  10. Grayburn PA, Hillis LD. Cardiac events in patients undergoing noncardiac surgery: shifting the paradigm from noninvasive risk stratification to therapy. Ann Intern Med Mar 2003;138:506-11. (review arguing that prophylaxis is more important than defining the extent of CAD)

  11. Kim LJ, Martinez EA, Faraday N, Dorman T, Fleisher LA, Perler BA, Williams GM, Chan D, Pronovost PJ. Cardiac troponin I predicts short-term mortality in vascular surgery patients. Circulation 2002;106:2366-71. (troponin leak dramatically increases perioperative and 6 month MI risk, with a dose-response relationship)

  12. Landesberg G. The pathophysiology of perioperative myocardial infarction: Facts and perspectives. J Cardiothorac Vasc Anesth 2003;17:90-100. (review of pathophysiology, including plaque rupture, increased demand, and prolonged stress)

  13. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043-9. (Six

  14. independent predictors of complications were identified: highrisk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine > 2.0 mg/dl)

  15. Licker M, Khatchatourian G, Schweizer A, Bednarkiewicz M, Tassaux D, Chevalley C. The impact of a cardioprotective protocol on the incidence of cardiac complications after aortic abdominal surgery. Anesth Analg 2002;95:1525-33. (Retrospective database review demonstrating that a clinical pathway incorporating preoperative clonidine and postoperative beta blockade aimed at

  16. keeping HR < 80 protects the heart)

  17. Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin EM. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA 2004;291:2092-9. (Large retrospective study suggesting that statins are associated with an odds ratio for death of 0.62 in elderly patients undergoing major noncardiac surgery, and that the number needed to treat to prevent one death was 30 among those with a revised cardiac risk index score of 4 or more)

  18. L’Italien GJ, Paul SD, Hendel RC, Leppo JA, Cohen MC, Fleisher LA, Brown KA, Zarich SW, Cambria RP, Cutler BS, Eagle KA. Development and validation of a Bayesian model for perioperative cardiac risk assessment in a cohort of 1,081 vascular surgical candidates. J Am Coll Cardiol 1996;27:779-86. (age, diabetes, CHF, previous MI, positive stress test increase risk; past CABG is protective)

  19. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996;335:1713-20.(perioperative beta blockade with atenolol has survival benefits that last for 2 years)

  20. McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004;351:2795-804. (Aggressive medical therapy appears as efficacious as coronary revascularization)

  21. Norris EJ, Beattie C, Perler BA, et al. Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery. Anesthesiology 2001;95:1054-67. (well-designed trial suggesting that anesthetic technique does not affect cardiac outcome after abdominal aortic surgery if heart rate is well controlled in the ICU)

  22. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in highrisk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999;341:1789-94.

  23. (perioperatve beta blockade reduces perioperative mortality and infarction in high risk vascular surgery)

  24. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ 2000;321:1493-7. (regional anesthesia, especially spinals and thoracic epidurals, may be associated with reduced perioperative death and myocardial infarction)

  25. Tanaka K, Ludwig LM, Kersten JR, Pagel PS, Warltier DC. Mechanisms of cardioprotection by volatile anesthetics. Anesthesiology 2004;100:707-21. (Excellent review)

  26. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-67. (Tight glucose control between 80 and 110 mg/dl reduces mortality in surgical ICU patients)

  27. Zaugg M, Tagliente T, Lucchinetti E, Jacobs E, Krol M, Bodian C, Reich DL, Silverstein JH. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology 1999;91:1674-86. (beta blockade not only reduces troponin release, but hastens emergence and improves analgesia after general anesthesia)

  28. Armanious S, Wong DT, Etchells E, Higgins P, Chung F. Successful implementation of perioperative beta-blockade utilizing a multidisciplinary approach. Can J Anaesth 2003;50:131-6.

  29. Auerbach AD, Goldman L. beta-Blockers and reduction of cardiac events in noncardiac surgery:scientific review. JAMA 2002;287:1435-44.

  30. Boersma E, Poldermans D, Bax JJ, Steyerberg EW, Thomson IR, Banga JD, van De Ven LL, van Urk H, Roelandt JR. Predictors of cardiac events after major vascular surgery: Role of clinical characteristics, dobutamine echocardiography, and beta-blocker therapy. JAMA 2001;285:1865-73. (defines which patients most likely to benefit from beta blockade)

  31. Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000;355:773-8. Review.

  32. Charlson ME, MacKenzie CR, Ales K, Gold JP, Fairclough G Jr, Shires GT. Surveillance for postoperative myocardial infarction after noncardiac operations. Surg Gynecol Obstet 1988;167:407- 14. (defines which patients on clinical criteria likely to rule-in for MI; suggested “rule-out” algorithm)

  33. Durazzo AE, Machado FS, Ikeoka DT, De Bernoche C, Monachini MC, Puech-Leao P, Caramelli B. Reduction in cardiovascular events after vascular surgery with atorvastatin: a randomized triRevista Mexicana de Anestesiología Ellis JE. Myocardial ischemia and postoperative management MG S66 al. J Vasc Surg 2004;39:967-75. (statins started roughly a month before vascular surgery and continued until 2 weeks after surgery reduced cardiac events)

  34. Ellis JE, Drijvers G, Pedlow S, Laff SP, Sorrentino MJ, Foss JF, Shah M, Busse JR, Mantha S, McKinsey JF, et al. Premedication with oral and transdermal clonidine provides safe and efficacious postoperative sympatholysis. Anesth Analg 1994;79:1133-40. (clondine premedication reduces heart rate and intraoperative myocardial ischemia)

  35. Fleisher LA, Eagle KA. Lowering Cardiac Risk in Noncardiac Surgery. N Engl J Med 2001;345:1677-1682. (succinct, evidence-based review)

  36. Frank SM, Fleisher LA, Breslow MJ, Higgins MS, Olson KF, Kelly S, Beattie C. Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 1997;277:1127-34. (forced air warming reduces cardiac complications)

  37. Grayburn PA, Hillis LD. Cardiac events in patients undergoing noncardiac surgery: shifting the paradigm from noninvasive risk stratification to therapy. Ann Intern Med Mar 2003;138:506-11. (review arguing that prophylaxis is more important than defining the extent of CAD)

  38. Kim LJ, Martinez EA, Faraday N, Dorman T, Fleisher LA, Perler BA, Williams GM, Chan D, Pronovost PJ. Cardiac troponin I predicts short-term mortality in vascular surgery patients. Circulation 2002;106:2366-71. (troponin leak dramatically increases perioperative and 6 month MI risk, with a dose-response relationship)

  39. Landesberg G. The pathophysiology of perioperative myocardial infarction: Facts and perspectives. J Cardiothorac Vasc Anesth 2003;17:90-100. (review of pathophysiology, including plaque rupture, increased demand, and prolonged stress)

  40. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KK, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation 1999;100:1043-9. (Six independent predictors of complications were identified: highrisk type of surgery, history of ischemic heart disease, history of congestive heart failure, history of cerebrovascular disease, preoperative treatment with insulin, and preoperative serum creatinine › 2.0 mg/dl)

  41. Licker M, Khatchatourian G, Schweizer A, Bednarkiewicz M, Tassaux D, Chevalley C. The impact of a cardioprotective protocol on the incidence of cardiac complications after aortic abdominal surgery. Anesth Analg 2002;95:1525-33. (Retrospective database review demonstrating that a clinical pathway incorporating preoperative clonidine and postoperative beta blockade aimed at keeping HR ‹ 80 protects the heart)

  42. Lindenauer PK, Pekow P, Wang K, Gutierrez B, Benjamin EM. Lipid-lowering therapy and in-hospital mortality following major noncardiac surgery. JAMA 2004;291:2092-9. (Large retrospective study suggesting that statins are associated with an odds ratio for death of 0.62 in elderly patients undergoing major noncardiac surgery, and that the number needed to treat to prevent one death was 30 among those with a revised cardiac risk index score of 4 or more)

  43. L’Italien GJ, Paul SD, Hendel RC, Leppo JA, Cohen MC, Fleisher LA, Brown KA, Zarich SW, Cambria RP, Cutler BS, Eagle KA. Development and validation of a Bayesian model for perioperative cardiac risk assessment in a cohort of 1,081 vascular surgical candidates. J Am Coll Cardiol 1996;27:779-86. (age, diabetes, CHF, previous MI, positive stress test increase risk; past CABG is protective)

  44. Mangano DT, Layug EL, Wallace A, Tateo I. Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery. Multicenter Study of Perioperative Ischemia Research Group. N Engl J Med 1996;335:1713-20.(perioperative beta blockade with atenolol has survival benefits that last for 2 years)

  45. McFalls EO, Ward HB, Moritz TE, Goldman S, Krupski WC, et al. Coronary-artery revascularization before elective major vascular surgery. N Engl J Med 2004;351:2795-804. (Aggressive medical therapy appears as efficacious as coronary revascularization)

  46. Norris EJ, Beattie C, Perler BA, et al. Double-masked randomized trial comparing alternate combinations of intraoperative anesthesia and postoperative analgesia in abdominal aortic surgery. Anesthesiology 2001;95:1054-67. (well-designed trial suggesting that anesthetic technique does not affect cardiac outcome after abdominal aortic surgery if heart rate is well controlled in the ICU)

  47. Poldermans D, Boersma E, Bax JJ, et al. The effect of bisoprolol on perioperative mortality and myocardial infarction in highrisk patients undergoing vascular surgery. Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography Study Group. N Engl J Med 1999;341:1789-94. (perioperatve beta blockade reduces perioperative mortality and infarction in high risk vascular surgery)

  48. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, Sage D, Futter M, Saville G, Clark T, MacMahon S. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomized trials. BMJ 2000;321:1493-7. (regional anesthesia, especially spinals and thoracic epidurals, may be associated with reduced perioperative death and myocardial infarction)

  49. Tanaka K, Ludwig LM, Kersten JR, Pagel PS, Warltier DC. Mechanisms of cardioprotection by volatile anesthetics. Anesthesiology 2004;100:707-21. (Excellent review)

  50. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-67. (Tight glucose control between 80 and 110 mg/dl reduces mortality in surgical ICU patients)

  51. Zaugg M, Tagliente T, Lucchinetti E, Jacobs E, Krol M, Bodian C, Reich DL, Silverstein JH. Beneficial effects from beta-adrenergic blockade in elderly patients undergoing noncardiac surgery. Anesthesiology 1999;91:1674-86. (beta blockade not only reduces troponin release, but hastens emergence and improves analgesia after general anesthesia)




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