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European Heart Journal Advance Access originally published online on January 17, 2008
European Heart Journal 2008 29(4):567-568; doi:10.1093/eurheartj/ehm601
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org

Intraoperative myocardial infarction in non-cardiac surgery: is a universal definition feasible? reply

Kristian Thygesen

Department of Medicine and Cardiology
Aarhus University Hospital
Tage Hansens gade 2
DK-8000 Aarhus C
Denmark
Tel: +45 89497614
Fax: +45 89497619
Email: kristian.thygesen{at}as.aaa.dt

Joseph S. Alpert

University of Arizona College of Medicine
Tucson, AZ
USA

Allan S. Jaffe

Mayo Clinic
Rochester, MN
USA

Harvey D. White On behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction

Auckland City Hospital
Auckland
New Zealand

The Joint ESC/ACCF/AHA/WHF Task Force appreciates the letter of Dr Siniorakis and colleagues, which allows us to clarify its recommendations. We agree that there is a great deal to learn about peri- and post-operative myocardial infarction as the pathophysiology of these differs somewhat from that of myocardial infarction occurring in the usual setting. However there are substantial data to guide us.1,2 We also agree that many of these infarctions are likely type 2. This fact raises several important considerations and some caveats as well. Specifically:

  1. Studies of patients undergoing non-cardiac surgery strongly support the concept that many of the infarctions diagnosed in this connection are caused by prolonged imbalance between myocardial oxygen supply and demand on the background of coronary artery disease,1,2 which together with rise and fall of cardiac markers points towards myocardial infarction type 2.
  2. The fact that many such patients have type 2 infarctions should not obscure the likelihood that some of the infarctions are type 1 as well. Pathology of fatal peri- or post-operative myocardial infarctions shows plaque rupture and platelet aggregation leading to thrombus formation in approximately half of these events.3 Given the differences that likely exist in the therapeutic approaches to each, close clinical scrutiny to identify this group is essential.
  3. Some patients may not have myocardial infarction at all. Careful clinical evaluation including a detailed history, examination, and evaluation of further investigations to identify and treat those with pulmonary embolism, sepsis and/or the many other conditions associated with myocyte necrosis and troponin elevations also is strongly advocated.4
  4. The available data suggest not only the need for short-term strategies to improve prognosis but also the need to develop ways of evaluating those who do well short term but who are at accentuated risk longer term.5,6
Although there is still the need for data in specific subgroups of patients with peri- or post-operative myocardial infarction, the available information suggests that the use of contemporary troponin assays5,6 and the decision levels advocated by the expert consensus document on universal definition of myocardial infarction4 maximizes the ability to identify patients with this diagnosis and those at risk.

References

  1. Fleisher LA, Nelson AH, Rosenbaum SH. Postoperative myocardial ischemia: etiology of cardiac morbidity or manifestation of underlying disease? J Clin Anesth (1995) 7:97–102.[CrossRef][Web of Science][Medline]
  2. Landesberg G, Mosseri M, Shatz V, Akopnik I, Bocher M, Mayer M, Anner H, Berlatzky Y, Weissman C. Cardiac troponin after major vascular surgery: the role of perioperative ischemia, preoperative thallium scanning, and coronary revascularization. J Am Coll Cardiol (2004) 44:569–575.[Abstract/Free Full Text]
  3. Cohen MC, Aretz TH. Histological analysis of coronary artery lesions in fatal postoperative myocardial infarction. Cardiovasc Pathol (1999) 8:133–139.[CrossRef][Web of Science][Medline]
  4. Thygesen K, Alpert JS, White HD. Joint ESC/ACCF/AHA/WHF Task Force for the redefinition of myocardial infarction. Universal definition of myocardial infarction. Eur Heart J (2007) 28:2525–2538. J Am Coll Cardiol 2007;50:2173–2195; Circulation 2007;116:2634–2653.[Free Full Text]
  5. Landesberg G, Shatz V, Akopnik I, Wolf YG, Mayer M, Berlatzky Y, Weissman C, Mosseri M. Association of cardiac troponin, CK-MB, and postoperative myocardial ischemia with long-term survival after major vascular surgery. J Am Coll Cardiol (2003) 42:1547–1554.[Abstract/Free Full Text]
  6. Bursi F, Babuin L, Barbieri A, Politi L, Zennaro M, Grimaldi T, Rumolo A, Gargiulo M, Stella A, Modena MG, Jaffe AS. Vascular surgery patients: perioperative and long-term risk according to the ACC/AHA guidelines, the additive role of post-operative troponin elevation. Eur Heart J (2005) 26:2448–2456.[Abstract/Free Full Text]

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This Article
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