Myocardial injury after non-cardiac surgery

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Myocardial injury after non-cardiac surgery(myocardial injury after noncardiac surgery, MINS) is a term that was developed to categorise a group of patients with raised plasma cardiac proteins demonstrated after surgical operations, who have poorer outcome[1][2]. Some raise is common after say elective hip surgery and may have no significance, but it is possible with appropriate cut off criteria to define poor prognosis cut offs as defined in the VISION trial[3]. The subgroup of patients at increased risk was first defined in the 1990s.[4] Until 2018 interventions were purely preventive and restricted to optimising patients with high cardiovascular risk pre-surgery[5]. In 2018 a reduction in mortality was demonstrated in a group of patients randomised in the MANAGE trial, to receive low dose dabigatran so offering promise with an intervention that could rapidly come to market[6]. The intervention is likely to be cost effective on standard criteria based on studies to date but this does not mean that it will not be costly to health systems.[7]

References

  1. Ekeloef S, Alamili M, Devereaux PJ, Gögenur I. Troponin elevations after non-cardiac, non-vascular surgery are predictive of major adverse cardiac events and mortality: a systematic review and meta-analysis. Br J Anaesth. 2016 Nov;117(5):559-568.
  2. Puelacher C, Lurati Buse G, Seeberger D, Sazgary L, Marbot S, Lampart A, Espinola J, Kindler C, Hammerer A, Seeberger E, Strebel I, Wildi K, Twerenbold R, du Fay de Lavallaz J, Steiner L, Gurke L, Breidthardt T, Rentsch K, Buser A, Gualandro DM, Osswald S, Mueller C; BASEL-PMI Investigators. Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization. Circulation. 2018 Mar 20;137(12):1221-1232.doi: 10.1161/CIRCULATIONAHA.117.030114
  3. Writing Committee for the VISION Study Investigators, Devereaux PJ, Biccard BM, Sigamani A, Xavier D, Chan MTV, Srinathan SK, Walsh M, Abraham V, Pearse R, Wang CY, Sessler DI, Kurz A, Szczeklik W, Berwanger O, Villar JC, Malaga G, Garg AX, Chow CK, Ackland G, Patel A, Borges FK, Belley-Cote EP, Duceppe E, Spence J, Tandon V, Williams C, Sapsford RJ, Polanczyk CA, Tiboni M, Alonso-Coello P, Faruqui A, Heels-Ansdell D, Lamy A, Whitlock R, LeManach Y, Roshanov PS, McGillion M, Kavsak P, McQueen MJ, Thabane L, Rodseth RN, Buse GAL, Bhandari M, Garutti I, Jacka MJ, Schünemann HJ, Cortes OL, Coriat P, Dvirnik N, Botto F, Pettit S, Jaffe AS, Guyatt GH. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2017 Apr 25;317(16):1642-1651.doi: 10.1001/jama.2017.4360
  4. Lopez-Jimenez F, Goldman L, Sacks DB, Thomas EJ, Johnson PA, Cook EF, Lee TH. Prognostic value of cardiac troponin T after noncardiac surgery: 6-month follow-up data. J Am Coll Cardiol. 1997 May;29(6):1241-5.
  5. Hua A, Pattenden H, Leung M, Davies S, George DA, Raubenheimer H, Niwaz Z, Lim E. Early cardiology assessment and intervention reduces mortality following myocardial injury after non-cardiac surgery (MINS). J Thorac Dis. 2016 May;8(5):920-4. doi: 10.21037/jtd.2016.03.55.
  6. Devereaux PJ, Duceppe E, Guyatt G et al. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet 391(10137):2325–2334 2018doi: 10.1016/S0140-6736(18)30832-8
  7. Troponin T monitoring to detect myocardial injury after noncardiac surgery: a cost-consequence analysis. Can J Surg. 2018 Jun;61(3):185-194.