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Perioperative strategies to reduce risk of myocardial injury after non-cardiac surgery (MINS): A narrative review

March 26, 2023

Myocardial injury is a frequent complication of surgical patients after having non-cardiac surgery that is strongly associated with perioperative mortality. While intraoperative anesthesia-related deaths are exceedingly rare, about 1% of patients undergoing non-cardiac surgery die within the first 30 postoperative days. Given the number of surgeries performed annually, death following surgery is the second leading cause of death in the United States. Myocardial injury after non-cardiac surgery (MINS) is defined as an elevation in troponin con- centrations within 30 days postoperatively. Although typically asymptomatic, patients with MINS suffer myocardial damage and have a 10% risk of death within 30 days after surgery and excess risks of mortality that persist during the first postoperative year. Many factors for the development of MINS are non-modifiable, such as preexistent coronary artery disease. Preventive measures, systematic approaches to surveillance and treatment standards are still lacking, however many factors are modifiable and should be considered in clinical practice: the importance of hemodynamic control, adequate oxygen supply, metabolic homeostasis, the use of perioperative medications such as statins, anti-thrombotic agents, beta-blockers, or anti-inflammatory agents, as well as some evidence regarding the choice of sedative and analgesic for anesthesia are discussed. Also, as age and complexity bbreviations: ACS-NSQIP, American College of Surgeons National Surgical Quality Improvement Program; AHA, American Heart Association; ASCVD, athero- sclerotic cardiovascular disease calculator; BALANCED, Anesthetic Depth and Complications After Major Surgery; BNP/NT-proBNP, (N-terminal pro-) brain natri- uretic peptide; CAD, coronary artery disease; CI, cardiac index; CPB, cardiopulmonary bypass; COP-AF, Colchicine for the Prevention of Perioperative Atrial Fibrillation in Patients Undergoing Thoracic Surgery; COPMAN, Colchicine Prevents Myocardial Injury After Non-Cardiac Surgery Pilot Study; CRIPES, Cardiac Remote Ischemic Preconditioning Prior to Elective Vascular Surgery; cTn, cardiac troponin; cTnC, cardiac troponin C; cTnI, cardiac troponin I; cTnT, cardiac troponin T; CVD, cardiovascular disease; ENIGMA, Evaluation of Nitrous Oxide in the Gas Mixture for Anesthesia; INPRESS, Intraoperative Norepinephrine to Control Arterial Pressure; FiO2, fraction of inspired oxygen; hsTnI, high-sensitivity troponin I; hsTnT, high-sensitivity troponin T; MANAGE, Dabigatran in patients with myocardial injury after non-cardiac surgery: an international, randomized, placebo-controlled trial; MAP, mean arterial blood pressure; MI, myocardial infarction; MINS, myocardial injury after non-cardiac surgery; POISE, Perioperative Ischemic Evaluation; POPCORN, Perioperative Colchicine to Reduce Negative Events; PROTECT, Aggressive intraoperative warming versus routine thermal management during non-cardiac surgery; RCRI, revised cardiac risk index; RCT, randomized controlled trial; SAS, Surgical Apgar Score; VISION, Vascular Events in Noncardiac Surgery Cohort Evaluation.