Long-term outcomes of perioperative myocardial infarction/injury after non-cardiac surgery

Abstract

Aims: Perioperative myocardial infarction/injury (PMI) following non-cardiac surgery is a frequent cardiac complication. Better understanding of the underlying aetiologies and outcomes is urgently needed.

Methods and results: Aetiologies of PMIs detected within an active surveillance and response programme were centrally adjudicated by two independent physicians based on all information obtained during clinically indicated PMI work-up including cardiac imaging among consecutive high-risk patients undergoing major non-cardiac surgery in a prospective multicentre study. PMI aetiologies were hierarchically classified into 'extra-cardiac' if caused by a primarily extra-cardiac disease such as severe sepsis or pulmonary embolism; and 'cardiac', further subtyped into type 1 myocardial infarction (T1MI), tachyarrhythmia, acute heart failure (AHF), or likely type 2 myocardial infarction (lT2MI). Major adverse cardiac events (MACEs) including acute myocardial infarction, AHF (both only from day 3 to avoid inclusion bias), life-threatening arrhythmia, and cardiovascular death as well as all-cause death were assessed during 1-year follow-up. Among 7754 patients (age 45-98 years, 45% women), PMI occurred in 1016 (13.1%). At least one MACE occurred in 684/7754 patients (8.8%) and 818/7754 patients died (10.5%) within 1 year. Outcomes differed starkly according to aetiology: in patients with extra-cardiac PMI, T1MI, tachyarrhythmia, AHF, and lT2MI 51%, 41%, 57%, 64%, and 25% had MACE, and 38%, 27%, 40%, 49%, and 17% patients died within 1 year, respectively, compared to 7% and 9% in patients without PMI. These associations persisted in multivariable analysis.

Conclusion: At 1 year, most PMI aetiologies have unacceptably high rates of MACE and all-cause death, highlighting the urgent need for more intensive treatments.

Study registration: https://clinicaltrials.gov/ct2/show/NCT02573532.

Keywords: Major cardiac events; Myocardial injury; Non-cardiac surgery; Perioperative care; Risk factors; Risk prediction.

Structured Graphical Abstract

At 1 year, most PMI aetiologies have unacceptably high rates of major adverse cardiac event and all-cause death, highlighting the need for more comprehensive management strategies, taking different aetiologies, their incidence, and their associated outcomes into consideration. PMI was defined as an absolute increase in cTn from pre-operative to post-operative concentrations of at least the upper limit of normal of the used assay (for high sensitivity cTnT this corresponds to an increase of at least +14 ng/L, e.g. from 10 ng/L pre-operatively to ≥24 ng/L post-operatively). cTn, cardiac troponin; PMI, perioperative myocardial infarction/injury.

Figure 1

Patient flow. AMI, acute myocardial infarction; cTn, cardiac troponin; MACE, major adverse cardiac event; lT2MI, likely type 2 myocardial infarction; PMI, perioperative myocardial infarction/injury.

Figure 2

Distribution of adjudicated aetiology of perioperative myocardial infarction/injury in different surgical specialities. The size of the circle indicates the overall percentage of perioperative myocardial infarction/injury, and the different colours indicate the adjudicated aetiologies of perioperative myocardial infarction/injury following surgery in the respective specialities.

Figure 3

Major adverse cardiac events (part A) and all-cause death (part B) within 1-year stratified according to adjudicated aetiology of perioperative myocardial infarction/injury after non-cardiac surgery, including adjusted hazard ratios from multivariable Cox proportional hazards analysis [adjusted for age, sex, ESC/ESA surgery risk (low, medium, high risk of cardiac events), revised cardiac risk index class, centre, surgical speciality, urgency of surgery, and post-operative complications (sepsis, stroke, bleeding)]. Grey dashed line denotes 120 day. MI, myocardial infarction.