Myocardial injury after non-cardiac surgery, or MINS, is a condition that affects approximately 20% of patients who undergo major surgery [1]. Unfortunately, there is a strong association between MINS and major surgical patients’ short-term and long-term mortalities [1]. Furthermore, it is a common condition [1]. A systematic review pooling outcomes from 530,867 surgeries determined the incidence of MINS to be at 18% [1]. This high level of risk, combined with the fact that most MINS cases are asymptomatic, highlights the importance of preventing, detecting, and treating MINS [1].
MINS is characterized by post-operative troponin measurements exceeding the 99th percentile of the assay’s upper reference limit [1, 2]. These elevated levels are typically found during or within the first thirty days following a non-cardiac operation [2]. MINS can occur without associated ischemic symptoms or an electrocardiography finding [2].
The probability of experiencing MINS depends on a variety of factors, such as demographics, cardiac history, and surgery type [1]. For one, older patients and male patients are more likely to suffer from MINS than their younger or female counterparts, respectively [1]. Cardiac conditions, such as prior heart failure, hypertension, and coronary artery disease also make an individual more likely to demonstrate signs of MINS following major surgery [3]. Relatedly, patients with concerning Duke Activity Status Index scores are also at heightened risk [1]. Emergency surgeries also carry a greater risk of the condition compared to elective procedures [1]. Physicians can order tests to ascertain patients’ reticulated platelet concentrations, natriuretic peptide concentrations, and post-exercise heart rate recovery, all of which can indicate a person’s likelihood of developing MINS [1].
Additionally, some intraoperative and postoperative occurrences can predict a patient’s likelihood of exhibiting MINS. One such occurrence is intraoperative blood loss [4]. An analysis of 15,926 non-cardiac surgical patients discovered an association between significant intraoperative bleeding and myocardial injury [4]. Moreover, postoperative hypotension, bleeding, pain, hypoxia, and tachycardia can all increase the risk that a patient suffers from MINS [5]. As a result, physicians should take the necessary steps to correct those conditions before they result in myocardial injury and be especially vigilant during the post-operative period.
Before surgery, there are a few preventative measures that may reduce the risk of MINS [6]. Aspirin and statins have been shown by some studies to lower the frequency of MINS [3, 6]. While metoprolol can reduce a patient’s risk of myocardial infarction in the perioperative period, it can also contribute to increased risk of stroke and mortality [6]. Angiotensin-converting enzyme inhibitors (ACE) and angiotensin II receptor blockers (ARP) should also be avoided if possible because of their positive correlation with MINS [3].
If a patient develops MINS following surgery, physicians may wish to initiate dabigatran treatments at a dose of 110 mg to be taken twice daily, along with low-dose aspirin if patients do not face a high risk of bleeding [2]. Statin therapy can also be helpful [2]. Physicians should consider cardiac catheterization if MINS patients exhibit recurring bouts of instability, perhaps because of heart failure or cardiac ischemia [2].
Myocardial injury after non-cardiac surgery can be a difficult condition to prevent and manage. However, early interventions can reduce patients’ risk of death [7]. To ensure that surgical patients do not suffer from myocardial injury, surveillance is key [1].
References
[1] K. Ruetzler et al., “Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association,” Circulation, p. e1-e19, October 2021. [Online]. Available: https://doi.org/10.1161/CIR.0000000000001024.
[2] P. J. Devereaux and W. Szczeklik, “Myocardial injury after non-cardiac surgery: diagnosis and management,” European Heart Journal, vol. 41, no. 32, p. 3083-3091, August 2020. [Online]. Available: https://doi.org/10.1093/eurheartj/ehz301.
[3] N. R. Smilowitz et al., “Myocardial Injury after Non-Cardiac Surgery: A Systematic Review and Meta-analysis,” Cardiology in Review, vol. 27, no. 6, p. 267-273, November 2020. [Online]. Available: https://doi.org/10.1097/CRD.0000000000000254.
[4] J. Park et al., “Intraoperative blood loss may be associated with myocardial injury after non-cardiac surgery,” PLoS One, vol. 16, no. 2, p. 1-11, February 2021. [Online]. Available: https://doi.org/10.1371/journal.pone.0241114.
[5] A. J. L. Jorge, E. T. Mesquita, and W. D. A. Martins, “Myocardial Injury after Non-cardiac Surgery – State of the Art,” Arquivos Brasileiros de Cardiologia, vol. 117, no. 3, p. 544-553, September 2021. [Online]. Available: https://doi.org/10.36660/abc.20200317.
[6] N. Kuthiah and C. Er, “Myocardial injury in non-cardiac surgery: complexities and challenges,” Singapore Medical Journal, vol. 61, no. 1, p. 6-8, January 2020. [Online]. Available: https://doi.org/10.11622/smedj.2020004.
[7] A. Hua et al., “Early cardiology assessment and intervention reduces mortality following myocardial injury after non-cardiac surgery (MINS),” Journal of Thoracic Disease, vol. 8, no. 5, p. 920-924, May 2016. [Online]. Available: https://doi.org/10.21037/jtd.2016.03.55.