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[Incidence and prevention of coronary complications after general surgery]
Insights
Cardiac complications after surgery, like acute myocardial infarction, can be prevented. Beta-blockers and potentially alpha-2-agonists can reduce cardiac risk in high-risk surgical patients.
Area of Science:
- Cardiology
- General Surgery
- Perioperative Medicine
Context:
- Cardiac complications are a significant concern for general surgical patients, particularly acute myocardial infarction.
- These events, often occurring within 48 hours post-surgery, jeopardize patient survival.
- Perioperative physiological changes contribute to myocardial ischemia and necrosis.
Purpose:
- To review the mechanisms of cardiac complications in general surgery.
- To discuss the role of perioperative management in reducing cardiac risk.
- To evaluate preventive strategies for acute myocardial infarction in surgical patients.
Summary:
- Acute myocardial infarction occurs in 3-5% of high-risk surgical patients, often subendocardial and asymptomatic.
- Perioperative circulatory, mechanical, inflammatory, and hypercoagulable changes disrupt myocardial energy balance, leading to ischemia.
- Monitoring hemodynamics and managing postoperative stress are crucial; beta-blockers show promise in prevention.
Impact:
- Highlights the importance of considering cardiac risk in surgical patients, especially those with coronary artery disease.
- Emphasizes proactive management through hemodynamic monitoring and pharmacological interventions like beta-blockers.
- Suggests alpha-2-agonists as a potential prophylactic measure pending further clinical trial results.
Abstract:
The frequency, the nature and physiopathological mechanisms of cardiac complications of general surgical patients are well known. Acute myocardial infarction, the main complication, occurs in 3 to 5% of high risk cases. Though usually subendocardial and asymptomatic, it jeopardizes short and medium term survival of patients. It occurs in the first 48 hours after surgery in the majority of cases, the diagnosis being confirmed by increased serum troponine I levels. The circulatory, mechanical and inflammatory changes and hypercoagulability, which are present during the perioperative period, interact, disturbing the energetic equilibrium of the myocardium and causing episodes of myocardial ischaemia which, if prolonged, result in necrosis of the subendocardial myocardium. These effects must be taken into consideration if the operative risk of coronary patients is to be reduced. It is essential to monitor the haemodynamic parameters which affect myocardial energy consumption both during and after surgery. Particular attention must be paid in the postoperative period which is characterised by metabolic stress and sympathetic hyperreactivity which predispose to prolonged episodes of silent myocardial ischaemia. Betablockers, which effectively prevent per and postoperative ischaemia without causing jeopardy to the haemodynamic status and which reduce the cardiac risk of general surgery have a role to play in the prevention of acute myocardial infarction in the postoperative period when prescribed before surgery and continued by oral administration during the first 6 postoperative days. The alpha-2-agonists affect sympathetic reactivity during and after surgery and are very well tolerated haemodynamically. If the current on-going multicenter trials show that they prevent postoperative cardiovascular complications, they could be prescribed prophylactically in patients at risk.