BJA Advance Access originally published online on April 19, 2004
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British Journal of Anaesthesia, 2004, Vol. 93, No. 1 9-20
© 2004 The Board of Management and Trustees of the British Journal of Anaesthesia
Triggers of perioperative myocardial ischaemia and infarction
University Hospital/Department of Anaesthesia, Hugstetter Str. 55, 79106 Freiburg, Germany. E-mail: priebe@ana1.ukl.uni-freiburg.de
Keywords: complications, myocardial ischaemia; complications, myocardial infarction; surgery, non-cardiac
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Introduction |
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Cardiac complications are a major cause of morbidity and mortality after non-cardiac surgery.58 64 However, the exact nature of perioperative myocardial injury remains elusive and an area of continued debate and controversy.50 64 If triggers of perioperative myocardial ischaemic events could be identified, appropriately taken preventive measures might improve perioperative cardiac outcome. Identification of possible triggers of perioperative myocardial ischaemia and infarction requires knowledge of their incidence, diagnosis and characteristics; of the pathophysiology of acute coronary syndromes (ACS) in the non-surgical setting; and of factors and interventions that have been shown to affect perioperative myocardial injury. The following review will address these areas before attempting to define the possible mechanisms and triggers of perioperative myocardial ischaemia and infarction.
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Incidence of perioperative myocardial ischaemia and infarction |
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Incidence of perioperative myocardial ischaemia
In patients with or at risk of coronary artery disease, the reported incidence of perioperative myocardial ischaemia varies considerably, i.e. between 20 and 63%.27 46 49 58–61 81–83 87 In studies that examined the incidence of myocardial ischaemia throughout
Incidence of perioperative myocardial infarction
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Definition and diagnosis of perioperative myocardial ischaemia and infarction |
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Definition and diagnosis of perioperative myocardial ischaemia
Definition and diagnosis of perioperative myocardial infarction
Characteristics of postoperative myocardial ischaemia
Characteristics of postoperative myocardial infarction
Clinical and electrophysiological characteristics
Pathological characteristics
Angiographic characteristics
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Pathophysiology of myocardial ischaemia |
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Pathophysiology of myocardial infarction |
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Structural and functional characteristics of acute coronary syndromes |
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Structurally vulnerable plaques
Functionally vulnerable plaques
Complex coronary artery stenoses
Coronary endothelial erosions
Plaque inflammation
Plaque progression
Pathogenesis of plaque rupture
Physical factors in plaque rupture
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Factors and interventions affecting perioperative cardiac outcome |
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Factors associated with postoperative myocardial ischaemia
Interventions associated with improved perioperative cardiac outcome
ß-Adrenoceptor antagonists
2-Adrenoceptor agonistsAspirin
Statins
Mechanisms and triggers of perioperative myocardial injury
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Conclusions |
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