Background:
Each year, millions of patients worldwide have a perioperative myocardial infarction (MI) after noncardiac surgery.
Objective:
To examine the characteristics and short-term outcome of perioperative MI.
Design:
Cohort study. (ClinicalTrials.gov registration number: NCT00182039)
Setting:
190 centers in 23 countries.
Patients:
8351 patients included in the POISE (PeriOperative ISchemic Evaluation) trial.
Measurements:
Four cardiac biomarker or enzyme assays were measured within 3 days of surgery. The definition of perioperative MI included either autopsy findings of acute MI or an elevated level of a cardiac biomarker or enzyme and at least 1 of the following defining features: ischemic symptoms, development of pathologic Q waves, ischemic changes on electrocardiography, coronary artery intervention, or cardiac imaging evidence of MI.
Results:
Within 30 days of random assignment, 415 patients (5.0%) had a perioperative MI. Most MIs (74.1%) occurred within 48 hours of surgery; 65.3% of patients did not experience ischemic symptoms. The 30-day mortality rate was 11.6% (48 of 415 patients) among patients who had a perioperative MI and 2.2% (178 of 7936 patients) among those who did not (P < 0.001). Among patients with a perioperative MI, mortality rates were elevated and similar between those with (9.7%; adjusted odds ratio, 4.76 [95% CI, 2.68 to 8.43]) and without (12.5%; adjusted odds ratio, 4.00 [CI, 2.65 to 6.06]) ischemic symptoms.
Limitation:
Cardiac markers were measured only until day 3 after surgery, and additional asymptomatic MIs may have been missed.
Conclusion:
Most patients with a perioperative MI will not experience ischemic symptoms. Data suggest that routine monitoring of troponin levels in at-risk patients is needed after surgery to detect most MIs, which have an equally poor prognosis regardless of whether they are symptomatic or asymptomatic.
Primary Funding Source:
Canadian Institutes of Health Research.
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Author, Article and Disclosure Information
From McMaster University, Hamilton, Ontario, Canada; St. John's Medical College and St. John's Research Institute, Bangalore, India; Hospital General Universitario Gregorio Marañon, Madrid, Spain; Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia; University of Ottawa, Ottawa, Ontario, Canada; University of Alberta, Edmonton, Alberta, Canada; Dante Pazzanese Institute of Cardiology, São Paulo, Brazil; Université
de Sherbrooke, Sherbrooke, Quebec, Canada; and Anshan Iron and Steel Mining Company Hospital Gongchangling, Gongchangling, China.
Grant Support: By the Canadian Institutes of Health Research, the Commonwealth Government of Australia's National Health and Medical Research Council, the Instituto de Salud Carlos III (PI071071, Ministerio de Sanidad y Consumo) in Spain, the British Heart Foundation, and AstraZeneca.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2129.
Reproducible Research Statement:Study protocol: Available from Dr. Devereaux (e-mail, [email protected]
Corresponding Author: P.J. Devereaux, MD, PhD, Population Health Research Institute, David Braley Cardiac, Vascular, and Stroke Research Institute, Room C1-116, Perioperative Medicine and Surgical Research Unit, Hamilton General Hospital, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada; e-mail, [email protected]
Current Author Addresses: Drs. Devereaux and Yusuf, Ms. Pogue, Ms. Rao-Melacini, and Ms. Chrolavicius: Population Health Research Institute, David Braley Cardiac, Vascular, and Stroke Research Institute, Room C1-116, Perioperative Medicine and Surgical Research Unit, Hamilton General Hospital, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
Drs. Xavier and Sigamani: Division of Clinical Trials, St. John's Research Institute, Bangalore, Karnataka 560034, India.
Dr. Guyatt: 2C12, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario L8N 3Z5, Canada.
Dr. Garutti: Department of Anesthesiology, Hospital General Gregorio Marañon, St/Doctor Esquerdo 46, Madrid 28009, Spain.
Dr. Leslie: Royal Melbourne Hospital, Department of Anaesthesia and Pain Management, Grattan Street, Parkville, Victoria 3050, Australia.
Dr. Yang: Department of Anesthesiology, The Ottawa Hospital, University of Ottawa, B309, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.
Dr. MacDonald: 304 6203 28 Avenue, Edmonton, Alberta T6L 6K3, Canada.
Dr. Avezum: Dante Pazzanese Institute of Cardiology, São Paulo, 500 Av. Dante Pazzanese, São Paulo, Brazil 04012-909.
Dr. Lanthier: Centre Hospitalier Universitaire de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, J1H 5N4 Québec, Canada.
Dr. Hu: Anshan Iron and Steel Mining Company Hospital Gongchangling, Anshan Liaoning, China 114021.
Author Contributions: Conception and design: J. Pogue, H. Yang.
Analysis and interpretation of the data: D. Xavier, J. Pogue, S. Chrolavicius, H. Yang, A. Avezum.
Drafting of the article: J. Pogue, A. Sigamani, H. Yang, A. Avezum.
Critical revision of the article for important intellectual content: D. Xavier, A. Sigamani, I. Garutti, K. Leslie, P. Rao-Melacini, H. Yang, A. Avezum, L. Lanthier.
Final approval of the article: P.J. Devereaux, D. Xavier, J. Pogue, G. Guyatt, I. Garutti, K. Leslie, S. Chrolavicius, H. Yang, C. MacDonald, A. Avezum, L. Lanthier.
Provision of study materials or patients: D. Xavier, I. Garutti, H. Yang, C. MacDonald, W. Hu.
Statistical expertise: J. Pogue, P. Rao-Melacini.
Obtaining of funding: K. Leslie, H. Yang.
Administrative, technical, or logistic support: D. Xavier, H. Yang.
Collection and assembly of data: D. Xavier, J. Pogue, A. Sigamani, I. Garutti, K. Leslie, S. Chrolavicius, H. Yang, L. Lanthier.
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