Monitoring und Behandlung perioperativer kardiovaskulärer Erkrankungen

Zusammenfassung

Nach der koronaren Herzerkrankung und dem Schlaganfall stellt perioperative Mortalität die dritthäufigste Todesursache in den westlichen Industrieländern dar. Die individuelle, klinische Risikobewertung ist deswegen von besonderer Bedeutung. Die perioperative Mortalität beruht zum überwiegenden Anteil auf perioperativen Myokardinfarkten (PMI), die häufig klinisch stumm verlaufen und nur durch systematische hs-TnT/I-Messungen frühzeitig erkennbar werden. In den neuesten ESC-Leitlinien zu nicht kardialen, chirurgischen Eingriffen wird deswegen die perioperative hs-TnT/I-Überwachung empfohlen. Dadurch sollen Typ-1- und Typ-2-Myokardinfarkte schneller erkannt und behandelt werden. Auch nicht koronare Ursachen wie Herzrhythmusstörungen, Infektionen, Sepsis, Lungenembolie, Nierenfunktionsstörungen, Schlaganfall, Subarachnoidalblutung und chronische Lungenerkrankungen können zu einem hs-TnT/I-Anstieg führen. Da viele Hochrisikopatienten bereits präoperativ erhöhte hs-TnT/I-Werte aufweisen, sollte eine hs-TnT/I-Bestimmung bereits präoperativ durchgeführt werden.

Abstract

Perioperative mortality is the third most common cause of death after ischemic heart disease and stroke. Individual clinical risk assessment is therefore crucial. A relevant contribution to postoperative mortality is made by perioperative myocardial infarctions (PMI). In the majority of cases, these are clinically silent and are only recognized by systematic hs-TnT/I measurements. In the latest ESC guidelines for non-cardiac surgery, perioperative hs-TnT/I monitoring is, therefore, recommended. This is intended to detect and treat type 1 and type 2 myocardial infarctions more quickly. However, non-coronary causes such as cardiac arrhythmias, infections, sepsis, pulmonary embolism, renal dysfunction, stroke, subarachnoid hemorrhage and chronic lung diseases can also increase hs-TnT/I levels. Since many high-risk patients already have elevated hs-TnT/I values, preoperative assessment of hs-TnT/I levels should be performed.

Was ist wichtig?

• Die perioperative Mortalität bei nicht kardialen Operationen beträgt 1–2%.

• Dabei beruhen 50% auf kardiovaskulären Komplikationen wie perioperativer Myokardinfarkt (PMI).

• Durch perioperative Bestimmungen von hs-TnT/I werden PMI früher erkannt.

• Zur weiteren Differenzierung von nicht kardialen und kardialen Ursachen ist eine Echokardiografie notwendig.

Schlüsselwörter

Myokardischämie - perioperative Myokardverletzung - hs-Troponin

Keywords

myocardial ischemia - hs-troponin - perioperative myocardial injury (PMI)

Publication History

Article published online:
08 February 2024

• Literatur

• 1 Smilowitz NR, Gupta N, Ramakrishna H. et al. Perioperative Major Adverse Cardiovascular and Cerebrovascular Events Associated With Noncardiac Surgery. JAMA Cardiol 2017; 2: 181-187 DOI: 10.1001/jamacardio.2016.4792. (PMID: 28030663)
• 2 Spence J, LeManach Y, Chan MTV. Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study Investigators. et al. Association between complications and death within 30 days after noncardiac surgery. CMAJ 2019; 191: E830-E837 DOI: 10.1503/cmaj.190221. (PMID: 31358597)
• 3 Mangano DT, Browner WS, Hollenberg M. et al. Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group. JAMA 1992; 268: 233-239 DOI: 10.1001/jama.268.2.233. (PMID: 1608143)
• 4 Halvorsen S, Mehilli J, Cassese S. et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43: 3826-3924 DOI: 10.1093/eurheartj/ehac270. (PMID: 36017553)
• 5 Sazgary L, Puelacher C, Lurati Buse G. et al. Incidence of major adverse cardiac events following non-cardiac surgery. Eur Heart J Acute Cardiovasc Care 2020; 10: 550-558 DOI: 10.1093/ehjacc/zuaa008. (PMID: 33620378)
• 6 Botto F, Alonso-Coello P, Chan MT. et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology 2014; 120: 564-578 DOI: 10.1097/ALN.0000000000000113. (PMID: 24534856)
• 7 Gualandro DM, Puelacher C, LuratiBuse G. et al. Comparison of high-sensitivity cardiac troponin I and T for the prediction of cardiac complications after non-cardiac surgery. Am Heart J 2018; 203: 67-73 DOI: 10.1016/j.ahj.2018.06.012. (PMID: 30041065)
• 8 Puelacher C, LuratiBuse G, Seeberger D. et al. Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization. Circulation 2018; 137: 1221-1232 DOI: 10.1161/CIRCULATIONAHA.117.030114. (PMID: 29203498)
• 9 Smilowitz NR, Gupta N, Guo Y. Perioperative acute myocardial infarction associated with non-cardiac surgery. Eur Heart J 2017; 38: 2409-2417 DOI: 10.1093/eurheartj/ehx313. (PMID: 28821166)
• 10 Devereaux PJ, Sessler DI. Cardiac Complications in Patients Undergoing Major Noncardiac Surgery. N Engl J Med 2015; 373: 2258-2269 DOI: 10.1056/NEJMra1502824. (PMID: 26630144)
• 11 Sabate S, Mases A, Guilera N. et al. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth 2011; 107: 879-890 DOI: 10.1093/bja/aer268. (PMID: 21890661)
• 12 Devereaux PJ, Biccard BM, Sigamani A. Writing Committee for the VISION Study Investigators. et al. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA 2017; 317: 1642-1651 DOI: 10.1001/jama.2017.4360. (PMID: 28444280)
• 13 Group PS, Devereaux PJ, Yang H. et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371: 1839-1847 DOI: 10.1016/S0140-6736(08)60601-7. (PMID: 18479744)
• 14 Toda H, Nakamura K, Shimizu K. et al. Effects of Bisoprolol Transdermal Patches for Prevention of Perioperative Myocardial Injury in High-Risk Patients Undergoing Non-Cardiac Surgery – Multicenter Randomized Controlled Study. Circ J 2020; 84: 642-649 DOI: 10.1253/circj.CJ-19-0871. (PMID: 32092717)
• 15 Mangano DT. Perioperative medicine: NHLBI working group deliberations and recommendations. J Cardiothorac Vasc Anesth 2004; 18: 1-6 DOI: 10.1053/j.jvca.2003.10.002. (PMID: 14973791)
• 16 Smilowitz NR, Banco D, Katz SD. et al. Association between heart failure and perioperative outcomes in patients undergoing non-cardiac surgery. Eur Heart J Qual Care Clin Outcomes 2021; 7: 68-75 DOI: 10.1093/ehjqcco/qcz066. (PMID: 31873731)
• 17 Konstantinides SV, Meyer G, Becattini C. et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020; 41: 543-603 DOI: 10.1093/eurheartj/ehz405. (PMID: 31504429)