View source for Perioperative management of cardiac ischemia

== Background ==

===Epidemiology===

*Represents 1-6% of cardiac events

===Etiology===

*Bleeding (35%)
*Cardiac cause (44%), including MI, AV block, arrhythmias
*Other (21%), including PE, anaphylaxis, and hypoxemia

===Pathophysiology===

*Thrombosis
*Catecholamine surges from stress state
*Obstruction
*Infection or inflammation
*Increased demand, from tachycardia, fever, hypotension, anemia, and hypoxemia

==Clinical Manifestations==

*Highest risk period for MI is post-op day 3
*[[Myocardial infarction after non-cardiac surgery]] (MINS)
*[[STEMI]] is rare

==Diagnosis==

*Increased troponin with typical pattern
*Signs of ischemia, including Q waves on ECG or wall motion abnormalities on echocardiography

==Management==

*Treat underlying cause
*Add ASA and beta blocker, consider ACE inhibitor or nitrates

==Preoperative assessment==

*If surgery is emergent, proceed to OR
*If not emergent, then rule out ACS and treat this first
*If not having ACS, then risk stratify with AHA class or RCRI or NSQuIP
*Elective surgery should be delayed for:
**Anticoagulation/antiplatelets
**Electrolyte abnormalities
**Infection, especially pneumonia
**Obstructions in the vasculature (ACS or PE within the past month)
**Unstable vitals

==Prognosis==

*15-25% in-hospital mortality
*Outcomes are related to peak troponin (per VISION study)

[[Category:Perioperative medicine]]
[[Category:Cardiology]]