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[Perioperative diagnosis of acute myocardial ischemia]
1Abteilung für Klinische Anaesthesiologie, Heinrich-Heine-Universität Düsseldorf.
Insights
Coronary artery disease affects millions of surgical patients annually, increasing perioperative myocardial infarction risk. This review critically evaluates diagnostic methods for perioperative myocardial ischemia, focusing on practicality and cost-effectiveness.
Area of Science:
- Cardiology
- Anesthesiology
- Medical Diagnostics
Context:
- Coronary artery disease (CAD) significantly impacts cardiac and noncardiac surgery outcomes.
- An estimated 1 million of 8 million annual surgical patients in Germany have CAD, with 15,000 experiencing perioperative myocardial infarction.
- Early diagnosis and treatment of perioperative myocardial ischemia are crucial due to its link with cardiac morbidity and mortality.
Purpose:
- To critically evaluate diagnostic methods for myocardial ischemia in the perioperative setting.
- To assess the practicability and cost-benefit relationship of these diagnostic tools.
- To highlight the limitations of current methods in detecting perioperative myocardial ischemia.
Summary:
- Angina pectoris symptoms are unreliable perioperatively due to premedication, anesthesia, and analgesia.
- Standard electrocardiography (ECG) with ST-segment analysis detects myocardial ischemia with 80% sensitivity.
- Trans-esophageal echocardiography (TEE) is more sensitive than ECG but faces limitations in validation, false positives, detection of certain segments, invasiveness, training, and cost.
- Cardiokymography offers noninvasive anterior wall motion assessment.
Impact:
- Informs clinical decision-making regarding the optimal diagnostic strategy for perioperative myocardial ischemia.
- Highlights the need for improved, practical, and cost-effective diagnostic tools for myocardial ischemia in surgical patients.
- Emphasizes the limitations of current diagnostic modalities, particularly TEE, in the perioperative period.
Abstract:
The prevalence of coronary artery disease substantially affects both cardiac and noncardiac surgery. Assuming that biometric data reported from North America are representative for Germany, the following incidences can be estimated: around 1 million out of 8 million patients operated upon each year will suffer from coronary artery disease, and 15,000 of these patients will have a perioperative myocardial infarction. Since a close relationship has been shown between pre-, intra-, and postoperative myocardial ischaemia and postoperative cardiac morbidity and mortality, early diagnosis and therapy of acute perioperative myocardial ischaemia is warranted. The purpose of this review is to weigh critically the various methods for diagnosis of myocardial ischaemia in view of their practicability and cost/benefit relationship in the perioperative setting. The symptoms of angina pectoris are unreliable in the perioperative period, since patients are premedicated preoperatively, without symptoms during anaesthesia, and usually receive analgesics postoperatively. Intraoperative detection of myocardial ischaemia focuses on standard electrocardiography (ECG) with on-line registration of the ST-segment in two leads (usually leads II and V5) and automatic analysis of ST-segment deviation, achieving a sensitivity of 80% in the detection of myocardial ischaemia. Measurement of regional wall motion abnormalities with trans-esophageal echocardiography (TEE) is a more sensitive method of myocardial ischaemia detection compared to ECG. However, several reasons preclude the broader application of this method in the perioperative phase: (1) it lacks validation by an accepted and independent gold standard; (2) there is a wide spectrum of false-positive findings (considerable interindividual variations in left ventricular contraction, bundle branch blocks, hypertension, hypervolemia); (3) changes in the inferior and apical segments of the left ventricle cannot be detected by single-plane TOE. Detection in these segments might be achieved with biplane echocardiography, but few data on this improved technique are presently available; (4) the method is semi-invasive and might be not applicable during periods with a high incidence of myocardial ischaemia, e.g., intubation, the end of anaesthesia, and extubation; (5) anaesthetists seldom fulfil standard guidelines in echocardiography training; and (6) the method is expensive, which also limits its broader application. Cardiokymography, a noninvasive technique, allows analog representation of anterior wall motion.(ABSTRACT TRUNCATED AT 400 WORDS)