Perioperative myocardial infarction/injury (PMI) - NYSORA

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Perioperative myocardial infarction/injury (PMI)

Learning objectives

  • Describe the risk factors for PMI
  • Give prophylactic treatment to high-risk patients
  • Manage PMI cases

Definition & mechanisms

  • Postoperative myocardial injury/infarction (PMI) is a common complication after non-cardiac surgery
  • PMI is defined as the increase of troponin caused by ischemia within 30 days after surgery

Pathophysiology

  • Type I MI: plaque destruction followed by coronary atherosclerotic thrombosis
  • Type II MI: Imbalance in myocardial oxygen supply and demand resulting in ischemia

Risk factors

Patient-specificPrevious coronary artery disease
Age >70 years
Female sex
Renal failure
Diabetes
Peripheral artery disease
Emergency or redo surgery
Severe LV dysfunction (LVEF<35%) or cardiogenic shock
Intraoperative Open surgery
Prolonged intraoperative time with hypotension
Intraoperative heart rate of >110 or <55 BPM
Tachycardia
Intraoperative transfusions
Perioperative vasopressors
Postoperative Postoperative bleeding
Sepsis
Hypoxia
Sustained tachycardia
Hypotension
Severe anemia

Prophylaxis

  • β-adrenergic blockers
  • Calcium channel blockers 
  • α2 agonists
  • Statins 
  • Aspirin 
  • Coronary revascularization (requires further investigation)
  • Anemia corrections

Management

postoperative myocardial infarction injury ischemia, pmi, management, hemodynamic instability, tachycardia, pulmonary congestion, ecg, arterial blood gases, hypoxemia, hypercarbia, hemoglobin, troponin, ST-segment depression, ST-segment elevation, angiography, reperfusion, hypotension, tachyarrhythmia, invasive hemodynamic monitoring, echocardiography beta-blockers, calcium channel blockers, aspirin, nitroclycerine, morphine

Keep in mind

  • Careful perioperative monitoring for ischemia, a low threshold for treating and preventing tachycardia while avoiding hypotension, decreased cardiac output, and/or cardiac decompensation help prevent PMI
  • Coronary intervention is rarely indicated as the first line of treatment
  • Antithrombotic therapy may exacerbate bleeding

Suggested reading

  • Gao L, Chen L, He J, et al. Perioperative Myocardial Injury/Infarction After Non-cardiac Surgery in Elderly Patients. Front Cardiovasc Med. 2022;9:910879.
  • Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009;119(22):2936-2944.
  • Nashef S., Roques F., Michel P., et al. European system for cardiac operative risk evaluation. Eur J Cardiothorac Surg 1999; 16:9-13

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