scholarly journals Myocardial injury in noncardiac surgery – diagnostic difficulties

2020 ◽  
Vol 9 (3) ◽  
pp. 59-68
Author(s):  
S. S. Murashko ◽  
I. N. Pasechnik ◽  
S. A. Berns
Keyword(s):  
Myocardial Infarction ◽  
Myocardial Injury ◽  
Surgical Care ◽  
Myocardial Damage ◽  
Noncardiac Surgery ◽  
Cardiac Complications ◽  
Consensus Document ◽  
Long Term Prognosis ◽  
Universal Definition

A new concept was adopted by the Fourth Universal Definition of MI Expert Consensus Document in 2018 – periprocedural myocardial injury after cardiac- and noncardiac interventions, which is distinct from myocardial infarction.It is difficult to diagnose a heart attack and myocardial damage after noncardiac surgery.Postoperative myocardial injury increases mortality and worsens the long-term prognosis and quality of treatment.The quality of surgical care is determined by surgical techniques and the course of the postoperative period. Although complications often negate the results of brilliantly performed surgery, many of them would happen irrespective of surgeon`s actions. The development of complications determining the outcome of treatment can be associated with cardiac pathology. Cardiac complications may develop due to existing comorbidities, hemodynamic instability during surgery, cardiotoxic effect of drugs, etc. In 40% of cases, the risk of cardiac death after noncardiac surgery is associated with the development of perioperative myocardial infarction or myocardial injury. Myocardial infarction is the most demonstrative complication, although it is difficult to diagnose in the perioperative period in case of asymptomatic course. The link between postoperative myocardial infarction and lethality is beyond doubt. Adopted in 2018, the Fourth Universal Definition of MI Expert Consensus Document introduced a new concept of periprocedural myocardial injury after cardiac- and noncardiac interventions, which are distinct from myocardial infarction. Myocardial injury requires laboratory tests to be diagnosed. However, myocardial injury itself affects postoperative mortality and significantly worsens the long-term prognosis and quality of treatment. This article reports the features of the etiopathogenetic mechanisms of cardiac complications during surgical care, as well as the multifactorial genesis of myocardial injury. The analysis of modern scientific literature on the diagnosis of myocardial damage is given. The need for early diagnosis of myocardial damage to create optimal management tactics for patients undergoing noncardiac interventions is demonstrated.

scholarly journals Cardiac complications during the active phase of COVID-19: review of the current evidence

2021 ◽  
Author(s):  
Mohammad Said Ramadan ◽  
◽  
Lorenzo Bertolino ◽  
Tommaso Marrazzo ◽  
Maria Teresa Florio ◽  
...  
Keyword(s):  
Myocardial Injury ◽  
Myocardial Damage ◽  
Active Phase ◽  
Mortality Rates ◽  
Major Effect ◽  
Current Evidence ◽  
Cardiac Complications ◽  
Published Data ◽  
Improving Patient Care ◽  
Overall Mortality

AbstractGrowing reports since the beginning of the pandemic and till date describe increased rates of cardiac complications (CC) in the active phase of coronavirus disease 2019 (COVID-19). CC commonly observed include myocarditis/myocardial injury, arrhythmias and heart failure, with an incidence reaching about a quarter of hospitalized patients in some reports. The increased incidence of CC raise questions about the possible heightened susceptibility of patients with cardiac disease to develop severe COVID-19, and whether the virus itself is involved in the pathogenesis of CC. The wide array of CC seems to stem from multiple mechanisms, including the ability of the virus to directly enter cardiomyocytes, and to indirectly damage the heart through systemic hyperinflammatory and hypercoagulable states, endothelial injury of the coronary arteries and hypoxemia. The induced CC seem to dramatically impact the prognosis of COVID-19, with some studies suggesting over 50% mortality rates with myocardial damage, up from ~ 5% overall mortality of COVID-19 alone. Thus, it is particularly important to investigate the relation between COVID-19 and heart disease, given the major effect on morbidity and mortality, aiming at early detection and improving patient care and outcomes. In this article, we review the growing body of published data on the topic to provide the reader with a comprehensive and robust description of the available evidence and its implication for clinical practice.

Circulating Erythrocyte Microparticles and the Biochemical Extent of Myocardial Injury in ST Elevation Myocardial Infarction

Cardiology ◽  
2016 ◽  
Vol 136 (1) ◽  
pp. 15-20 ◽  
Author(s):  
Georgios Giannopoulos ◽  
Dimitrios A. Vrachatis ◽  
Georgios Oudatzis ◽  
Georgios Paterakis ◽  
Christos Angelidis ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Myocardial Injury ◽  
Troponin I ◽  
Multivariable Analysis ◽  
Area Under The Curve ◽  
Myocardial Damage ◽  
Primary Angioplasty ◽  
St Elevation Myocardial Infarction ◽  
Vascular Effects ◽  
St Elevation

Objectives: Red blood cell microparticles (RBCm) have potential adverse vascular effects and they have been shown to be elevated in ST elevation myocardial infarction (STEMI). The purpose of this study is to investigate their relationship with biochemical infarct size. Methods: RBCm were quantified with flow cytometry in blood drawn from 60 STEMI patients after a primary angioplasty. The creatine kinase-myocardial brain fraction (CK-MB) was measured at predefined time points and the area under the curve (AUC) was calculated. Results: RBCm count was correlated with CK-MB AUC (Spearman's ρ = 0.83, p < 0.001). The CK-MB AUC values per RBCm quartile (lower to upper) were: 3,351 (2,452-3,608), 5,005 (4,450-5,424), 5,903 (4,862-10,594), and 8,406 (6,848-12,782) ng × h/ml, respectively. From lower to upper quartiles, the maximal troponin I values were: 42.2 (23.3-49.3), 49.6 (28.8-54.1), 59.2 (41.4-77.3), and 69.1 (48.0-77.5) ng/ml (p = 0.005). In multivariable analysis, RBCm remained a significant predictor of CK-MB AUC (standardized β = 0.63, adjusted p = 0.001). Conclusions: Erythrocyte microparticles appear to be related to the total myocardial damage biomarker output. The exact pathophysiologic routes, if any, for this interaction remain to be identified. However, these results suggest that erythrocytes may be a - thus far virtually ignored - player in the pathogenesis of ischemic injury.

Abstract 350: Assessment of Clinicians’ Attitudes and Knowledge About Cardiac Troponin Testing

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Sandeep Jain ◽  
Andrew Hammes ◽  
Eric Rudofker ◽  
Karen Ream ◽  
Andrew E Levy
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Troponin ◽  
Myocardial Injury ◽  
The United States ◽  
Advanced Practice ◽  
Attitudes And Knowledge ◽  
Universal Definition ◽  
Definition Of ◽  
Attending Physicians

In the United States, the positive predictive value (PPV) of cardiac troponin for type 1 myocardial infarction is substantially lower than in Europe (15% vs. 50%). Further, even with publication of the 4 th Universal Definition of Myocardial Infarction, recent studies have shown that inaccurate classification of myocardial injury is common among clinicians in the United States. These findings are at least partly attributable to clinicians’ knowledge and attitudes about cardiac troponin testing; a survey of these parameters has never been conducted. Clinicians at the University of Colorado completed a brief 8-question multiple-choice survey related to troponin use, definitions of myocardial infarction and clinical assessment of elevated troponin levels. The survey was distributed via secure email and administered electronically using the Qualtrics™ platform. Responses were anonymous, completion was estimated to take 3 minutes and a lottery award system was used as an incentive for participation. Respondents included trainees, advanced practice providers and attending physicians from internal medicine, emergency medicine and medical subspecialties. We plan to obtain a total of 300 responses with descriptive findings of preliminary results included below. The survey was completed by 114 clinicians: 37 interns (32%), 45 residents (39%), 9 advanced practice providers (8%), 11 fellows (10%), and 12 attending physicians (11%). Regarding indications for troponin testing, 93% (106/114) indicated that they “usually” or “always” check troponin levels in patients with chest pain. More interestingly, 46% (52/112) reported checking troponin on “undifferentiated patients” at least half the time. For troponin interpretation, 97% (110/114) of participants identified that troponin levels alone cannot rule in or rule out coronary artery disease. In contrast, only 36% (41/114) and 55% (63/114), respectively, identified the NPV and PPV of a contemporary troponin assay for type 1 MI. Further, only 50% (57/114) of respondents identified that the likelihood of type 1 MI increases as troponin levels increase. Three brief clinical vignettes revealed that, while 78% (89/114) and 74% (45/61) of participants, respectively, identified type 1 MI and type 2 MI presentations, only 40% (21/53) of respondents correctly identified a vignette for non-ischemic myocardial injury. Concordant with this finding, 54% (61/114) of clinicians correctly identified the 4 th Universal Definition of Myocardial Infarction. These preliminary findings highlight important facets of clinician attitudes and knowledge about troponin testing that help explain the poor PPV for troponin and diagnostic misclassification observed among U.S. clinicians. These results could help guide curricular and clinical decision support interventions designed to improve the use and interpretation of cardiac troponin testing.

scholarly journals Added value of subjective assessed functional capacity before non-cardiac surgery in predicting postoperative myocardial injury

2020 ◽  
pp. 204748732090691
Author(s):  
Marije Marsman ◽  
Judith AR van Waes ◽  
Remco B Grobben ◽  
Corien SA Weersink ◽  
Wilton A van Klei
Keyword(s):  
Myocardial Infarction ◽  
Cardiac Surgery ◽  
Functional Capacity ◽  
Myocardial Injury ◽  
Added Value ◽  
Cardiac Complications ◽  
Tertiary Referral Hospital ◽  
Postoperative Myocardial Infarction ◽  
Observational Cohort ◽  
One Year

Background Functional capacity is used as an indicator for cardiac testing before non-cardiac surgery and is often performed subjectively. However, the value of subjectively estimated functional capacity in predicting cardiac complications is under debate. We determined the predictive value of subjectively assessed functional capacity on postoperative cardiac complications and mortality. Design An observational cohort study in patients aged 60 years and over undergoing elective inpatient non-cardiac surgery in a tertiary referral hospital. Methods Subjective functional capacity was determined by anaesthesiologists. The primary outcome was postoperative myocardial injury. Secondary outcomes were postoperative inhospital myocardial infarction and one year mortality. Logistic regression analysis and area under the receiver operating curves were used to determine the added value of functional capacity. Results A total of 4879 patients was included; 824 (17%) patients had a poor subjective functional capacity. Postoperative myocardial injury occurred in 718 patients (15%). Poor functional capacity was associated with myocardial injury (relative risk (RR) 1.7, 95% confidence interval (CI) 1.5–2.0; P < 0.001), postoperative myocardial infarction (RR 2.9, 95% CI 1.9–4.2; P < 0.001) and one year mortality (RR 1.7, 95% CI 1.4–2.0; P < 0.001). After adjustment for other predictors, functional capacity was still a significant predictor for myocardial injury (odds ratio (OR) 1.3, 95% CI 1.0–1.7; P = 0.023), postoperative myocardial infarction (OR 2.0, 95% CI 1.3–3.0; P = 0.002) and one year mortality (OR 1.4, 95% CI 1.1–1.8; P = 0.003), but had no added value on top of other predictors. Conclusions Subjectively assessed functional capacity is a predictor of postoperative myocardial injury and death, but had no added value on top of other preoperative predictors.

The universal definition of myocardial infarction: a consensus document

Heart ◽  
2007 ◽  
Vol 94 (10) ◽  
pp. 1335-1341 ◽  
Author(s):  
J. S Alpert ◽  
K. Thygesen ◽  
A. Jaffe ◽  
H. D White
Keyword(s):  
Myocardial Infarction ◽  
Consensus Document ◽  
Universal Definition ◽  
Definition Of

scholarly journals Acute myocardial damage in new coronavirus infection (COVID-19)

2021 ◽  
Vol 20 (5) ◽  
pp. 98-104
Author(s):  
N. V. Izmozherova ◽  
A. A. Popov ◽  
A. I. Tsvetkov ◽  
M. A. Shambatov ◽  
I. P. Antropova ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Medical Care ◽  
Myocardial Injury ◽  
Troponin I ◽  
Myocardial Damage ◽  
True Incidence ◽  
Wide Range ◽  
Acute Myocardial Injury ◽  
Coronavirus Infection

Introduction. Acute respiratory distress syndrome (ARDS) and cardiovascular events, acute myocardial injury being the most frequent of the latter, are among the leading causes of death in COVID-19 patients. The lack of consensus on acute myocardial injury pathogenesis mechanisms, the patients management, treatment an rehabilitation logistics, the anticoagulant treatment in identified SARS-CoV-2 or suspected COVID-19 patients setting indicates the need to assess, analyze and summarize the available data on the issue.Materials and methods. Scientific publications search was carried out in PubMed, Google Scholar databases for the period from December 2019 to September 2021.Results and Discussion. Cardiospecific troponin I increase beyond reference limits is reported to occur in at least every tenth patient with identified SARS-CoV-2, the elevated troponin detection rate increasing among persons with moderate to severe course of the infection. The mechanisms of acute myocardial injury in patients with COVID-19 are poorly understood. By September 2021, there are several pathogenesis theories. A high frequency viral myocarditis direct cardiomyocytes damage is explained by the high SARS-CoV-2 affinity to ACE2 expressed in the myocardium. The cytokine storm related myocardial damage is reported a multiple organ failure consequence. Coagulopathy may also trigger myocardial microvessels damage. Up to every third death of SARS-CoV-2 infected persons is related to the acute myocardial injury. At the same time, due to the high incidence of the acute myocardial injury, it is rather difficult to assess the true incidence of acute myocardial infarction in patients with COVID-19. In the pandemic setting, the waiting time for medical care increases, the population, trying to reduce social contacts, is less likely to seek medical help. In this regard, in order to provide effective medical care to patients with acute myocardial infarction, it is necessary to develop algorithms for providing care adapted to the current epidemiological situation.Conclusion. The treatment of patients with probable development of acute myocardial damage against the background of new coronavirus infection should be performed in accordance with the current clinical guidelines. Anticoagulant therapy should be administered in a prophylactic dose under control of hemostasis parameters and a wide range of biochemical parameters.

scholarly journals Remote ischaemic conditioning for myocardial infarction or elective PCI: systematic review and meta-analyses of randomised trials

2018 ◽  
Vol 9 (1_suppl) ◽  
pp. 82-92 ◽  
Author(s):  
Paul M Haller ◽  
Kris G Vargas ◽  
Maria C Haller ◽  
Edita Piackova ◽  
Johann Wojta ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Percutaneous Coronary Intervention ◽  
Myocardial Injury ◽  
Myocardial Damage ◽  
Coronary Intervention ◽  
Mean Difference ◽  
Elective Percutaneous Coronary Intervention ◽  
Percutaneous Coronary ◽  
Remote Ischaemic Conditioning ◽  
Ischaemic Conditioning

Background: The efficacy of remote ischaemic conditioning in clinical trials of ST-segment elevation myocardial infarction (STEMI) or elective percutaneous coronary intervention is controversial. We aimed to systematically review and meta-analyse whether remote ischaemic conditioning reduces myocardial damage in those patients. Methods: We searched PubMed, Embase and Web of Science from inception until December 2017 for randomised clinical trials evaluating remote ischaemic conditioning versus a control group. Two independent reviewers extracted data of 23 trials (2118 patients with STEMI; 2048 patients undergoing elective percutaneous coronary intervention) which were meta-analysed using random-effects models. Results: Remote ischaemic conditioning reduced infarct size in STEMI patients when assessed by imaging (mean difference of infarct size as percentage of left ventricle −2.43, 95% confidence interval (CI) –4.37 to −0.48; P=0.01; I2=44%; n=925) or biomarkers related to myocardial injury (peak values of cardiac biomarker release reported as standardised mean difference −0.19, 95% CI −0.37 to −0.02; P=0.03; I2=58%; n=1483) and increased myocardial salvage index (mean difference 0.07, 95% CI 0.01 to 0.13; P=0.02; I2=49%; n= 636). Left ventricular ejection fraction was increased when assessed during the first days after STEMI (mean difference 1.53, 95% CI 0.23 to 2.83; P=0.02; I2=28%; n=1192). Remote ischaemic conditioning had no influence on biomarker values after elective percutaneous coronary intervention (standardised mean difference 0.06, 95% CI −0.17 to 0.30; P=0.59). Conclusions: Despite a statistically significant reduction of myocardial damage in STEMI patients, the magnitude of the reduction was small and a significant impact on clinical events is unlikely. With respect to elective percutaneous coronary intervention, remote ischaemic conditioning had no influence on myocardial injury and its use is not supported by our analysis.

Heparin-Coated Stents Do Not Protect Cancer Patients from Cardiac Complications after Noncardiac Surgery

2009 ◽  
Vol 75 (1) ◽  
pp. 61-65
Author(s):  
Karen L. Sherman ◽  
Shawn H. Obi ◽  
Gerard V. Aranha ◽  
Katherine A. Yao ◽  
Margo C. Shoup
Keyword(s):  
Myocardial Infarction ◽  
Cancer Patients ◽  
Stent Placement ◽  
Noncardiac Surgery ◽  
Coronary Stents ◽  
Cardiac Complications ◽  
Antithrombotic Agents ◽  
Positive Correlation ◽  
Patients With Cancer ◽  
Postoperative Myocardial Infarction

Previous studies regarding preoperative coronary stents and antithrombotic agents have excluded patients with cancer as a result of hypercoagulability. The objective of this study is to determine whether preoperative heparin-coated coronary stents are as safe in patients with cancer undergoing surgery as patients without cancer. Between February 2003 and February 2005, 29 patients had heparin-coated coronary stents placed before noncardiac surgery. The incidence of postoperative myocardial infarction (MI) and/or death was compared in patients with and without cancer, and outcomes were further evaluated based on preoperative antithrombotic status. Postoperative MI occurred in three of 13 (23%) patients with cancer compared with zero of 16 non-cancer patients. Patients with cancer were 9.6 times more likely to have a postoperative MI resulting in death compared with noncancer patients. There was a positive correlation between patients having cancer and having a postoperative MI ( r = 0.38, P = 0.044) and between patients with cancer being on antithrombotic medications during surgery and having a postoperative MI ( r = 0.567, P = 0.044). After stent placement, patients with cancer undergoing surgery experienced a higher incidence of postoperative MI resulting in death compared with noncancer patients despite continued antithrombotic use. In these patients, alternatives to stenting should be considered to avoid perioperative cardiac complications.

scholarly journals Myocardial Injury after Noncardiac Surgery

2014 ◽  
Vol 120 (3) ◽  
pp. 564-578 ◽  
Keyword(s):  
Diagnostic Criteria ◽  
Myocardial Injury ◽  
Cox Regression ◽  
Troponin T ◽  
Perioperative Complications ◽  
Population Attributable Risk ◽  
Noncardiac Surgery ◽  
Universal Definition ◽  
Definition Of ◽  
Diagnostic Criterion

Abstract Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Sign in / Sign up

Export Citation Format

Share Document