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Published on: July 17, 2012
Myocardial infarction after vascular surgery: the role of prolonged stress-induced, ST depression-type ischemia
G Landesberg1, M Mosseri, D Zahger
1Department of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, Ein-Kerem, Jerusalem, Israel. gio@cc.huji.ac.il
Insights
Prolonged silent ischemia, detected by ST-segment depression, significantly increases the risk of postoperative myocardial infarction (PMI) after vascular surgery. This prolonged ischemia is a key factor in most cardiac complications.
Area of Science:
- Cardiology
- Vascular Surgery
- Critical Care Medicine
Background:
- Silent ischemia is a known predictor of cardiac events in both general and postoperative populations.
- The precise relationship between silent stress-induced ischemia and infarction remains unclear, with debate on whether it's a marker of coronary artery disease or directly contributes to infarction.
Purpose of the Study:
- To investigate the association between silent ischemia and postoperative myocardial infarction (PMI).
- To determine if prolonged ischemia directly leads to infarction or is merely an indicator of underlying disease.
Main Methods:
- Continuous 12-lead ST-trend monitoring was used in 185 vascular surgery patients for 48–72 hours post-surgery.
- Ischemia duration was correlated with cardiac troponin-I (cTn-I) levels and postoperative cardiac outcomes.
- Postoperative myocardial infarction (PMI) was defined by elevated cTn-I (>3.1 ng/ml) with symptoms or ECG changes.
Main Results:
- Of 185 patients, 38 (20.5%) experienced ischemic events, primarily ST-segment depression.
- Twelve patients (6.5%) developed PMI, all linked to prolonged ischemia (average 226 min) and elevated cTn-I.
- Ischemia duration strongly correlated with peak and cumulative cTn-I levels (r=0.83 and r=0.78).
Conclusions:
- Prolonged ST depression-type ischemia is a direct precursor to myocardial infarction.
- This type of prolonged ischemia is significantly associated with most cardiac complications following vascular surgery.
Objectives:
The goal of this study was to investigate the nature of the association between silent ischemia and postoperative myocardial infarction (PMI).
Background:
Silent ischemia predicts cardiac morbidity and mortality in both ambulatory and postoperative patients. Whether silent stress-induced ischemia is merely a marker of extensive coronary artery disease or has a closer association with infarction has not been determined.
Methods:
In 185 consecutive patients undergoing vascular surgery, we correlated ischemia duration, as detected on a continuous 12-lead ST-trend monitoring during the period 48 h to 72 h after surgery, with cardiac troponin-I (cTn-I) measured in the first three postoperative days and with postoperative cardiac outcome. Postoperative myocardial infarction was defined as cTn-I >3.1 ng/ml accompanied by either typical symptoms or new ischemic electrocardiogram (ECG) findings.
Results:
During 11,132 patient-hours of monitoring, 38 patients (20.5%) had 66 transient ischemic events, all but one denoted by ST-segment depression. Twelve patients (6.5%) sustained PMI; one of those patients died. All infarctions were non-Q-wave and were detected by a rise in cTn-I during or immediately after prolonged, ST depression-type ischemia. The average duration ofischemia in patients with PMI was 226+/-164 min (range: 29 to 625), compared with 38+/-26 min (p = 0.0000) in 26 patients with ischemia but not infarction. Peak cTn-I strongly correlated with the longest, as well as cumulative, ischemia duration (r = 0.83 and r = 0.78, respectively). Ischemic ECG changes were completely reversible in all but one patient who had persistent new T wave inversion. All ischemic events culminating in PMI were preceded by an increase in heart rate (delta heart rate = 32+/-15 beats/min), and most (67%) of them began at the end of surgery and emergence from anesthesia.
Conclusions:
Prolonged, ST depression-type ischemia progresses to MI and is strongly associated with the majority of cardiac complications after vascular surgery.
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