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The Pathophysiology of Myocardial Ischemia and Perioperative Myocardial Infarction

Marli Smit1, A R Coetzee1, A Lochner2

  • 1Department of Anesthesiology and Critical Care, Stellenbosch University, Tygerberg Academic Hospital, Cape Town, South Africa.

Journal of Cardiothoracic and Vascular Anesthesia
|November 6, 2019
PubMed

Insights

Perioperative myocardial infarction is often caused by a mismatch in myocardial oxygen supply and demand (Type 2 myocardial infarction). Understanding this pathophysiology can help anesthesiologists prevent these cardiac events during noncardiac surgery.

Area of Science:

  • Cardiology
  • Anesthesiology
  • Critical Care Medicine

Background:

  • Ischemic heart disease is a leading global cause of death.
  • Perioperative ischemia and infarction pose significant risks during noncardiac surgery.
  • Understanding the distinct pathophysiology of acute coronary syndrome and stable angina is crucial.

Purpose of the Study:

  • To review the pathophysiology of acute coronary syndrome (ACS) and stable angina.
  • To explore the relevance of ACS and stable angina to perioperative myocardial infarction (MI) and myocardial injury.
  • To argue that Type 2 MI (myocardial oxygen delivery-demand mismatch) is the primary cause of perioperative MI.

Main Methods:

  • Review of existing literature on ischemic heart disease pathophysiology.
  • Analysis of ACS (Type 1 MI) mechanisms, including plaque rupture, thrombus formation, and spasm.
  • Analysis of stable angina mechanisms, focusing on fixed coronary stenosis and oxygen supply-demand mismatch.
  • Application of these pathophysiological concepts to the perioperative setting.
  • Argument for Type 2 MI as the predominant mechanism in perioperative MI.

Main Results:

  • Acute coronary syndrome (Type 1 MI) results from vulnerable plaque rupture leading to coronary occlusion.
  • Stable angina arises from a mismatch between myocardial oxygen supply and demand due to fixed coronary stenosis.
  • Type 2 MI, characterized by oxygen delivery-demand mismatch, is proposed as the most likely pathophysiology for perioperative myocardial infarctions.

Conclusions:

  • Awareness of Type 2 MI pathophysiology is key to understanding perioperative cardiac events.
  • Knowledge of Type 2 MI triggers can enable anesthesiologists to better predict and prevent perioperative myocardial infarctions.
  • Targeting oxygen delivery-demand mismatch may significantly reduce the incidence of perioperative myocardial injury.

Keywords:
acute coronary syndromemyocardial injury after non cardiac surgerypathophysiologyperi-operative myocardial infarctionstable angina

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