Perioperative myocardial infarction: invasive vs conservative approach

Abstract

Patients with a myocardial injury during and after noncardiac surgery have an elevated risk of death. They may have significant coronary artery disease amenable to revascularisation, but over 50% of these patients develop an infarct in territories without significant stenosis of the corresponding vessel, and the clinical presentation does not easily allow differentiation between these situations. Coronary angiography and revascularisation in surgical ­patients suffering perioperative cardiac events is therefore controversial. Coronary angiography with a view to possible revascularisation may be ­appropriate preoperatively in cases of significant left main coronary artery stenosis and moderate to severe inducible myocardial ischaemia in intermediate risk vascular patients. In the peri- and postoperative setting, coronary angiography is indicated with ST elevation and possibly persistent haemodynamic instability following a significant troponin rise. Late coronary angio­graphy after surgery may be indicated in vascular patients at a high risk for subsequent cardiac events. Coronary angiography may be contra­indicated in patients with comorbidities associated with poor intermediate term survival or uncertain acute coronary syndromes. All other generally accepted indications for coronary angiography in medical patients are far more controversial in surgical patients, because of the risk of perioperative bleeding. In these patients, the benefits of medical therapy alone may outweigh the risks of coronary angiography to identify coronary lesions amenable to revascularisation. The medical therapy of all surgical patients with a myocardial injury following noncardiac surgery should be intensified.