Perioperative vascular events and myocardial injury after noncardiac surgery in vascular surgery: An overview of the current emerging evidence and guidelines

Abstract

Vascular surgery is considered a high-risk noncardiac surgery. It is associated with an increased risk of cardiovascular events in the perioperative period. Preoperative assessment of risk using validated scales such as Revised Cardiac Risk Index, helps informing patients, surgeons, and anesthetists on the potential risk of cardiovascular events. Cardiac biomarkers, such as NT pro-brain natriuretic peptide (pro-BNP)/BNP, improve the sensitivity of these scales, in predicting potential serious perioperative cardiovascular outcomes. It is cost effective and quicker than other invasive or noninvasive procedures, usually done before any vascular surgery. Several interventions have been tested in trials for potentially preventing an event, but none have given good quality evidence for benefit, except the use of statins. Postoperatively, use of drugs to prevent a cardiovascular event has not been as effective as in the nonsurgical setting (aspirin, β-blockers, α2agonists, and angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers). Monitoring of highly sensitive troponins better predicts 30-day mortality in patients undergoing any noncardiac surgery. This event is called myocardial injury after noncardiac surgery (MINS) or in short MINS. Currently, MINS is not detected in over 75% of vascular surgery patients as it is not routinely performed. As per the evidence reviewed in this article and as recommended by the Canadian Cardiovascular Society Guidelines, it is imperative we monitor all patients aged above 45 years undergoing vascular surgery. Even though there is no evidence for an effective intervention of MINS, detections help in better monitoring of the patient and initiating effective secondary prevention treatment, as indicated.