Histological Analysis of Coronary Artery Lesions in Fatal Postoperative Myocardial Infarction

doi:10.1016/S1054-8807(98)00032-5

Cardiovascular Pathology

Volume 8, Issue 3, May–June 1999, Pages 133-139

https://doi.org/10.1016/S1054-8807(98)00032-5 Get rights and content

Abstract

We sought to evaluate the underlying coronary pathology of fatal postoperative myocardial infarction (MI). It has been hypothesized that most MIs following noncardiac surgery occur in the setting of increased oxygen demand that exceeds coronary blood supply. However, most MIs not associated with surgery are caused by plaque rupture and intracoronary thrombosis. In a retrospective cohort study, we reviewed 1841 consecutive autopsy records from 1981 to 1995 at two institutions and identified 26 cases of postoperative MI with coronary arteries available. Plaque rupture was present in 12 cases (46%, 95% confidence interval [CI] 27%–67%). Of the 9 (35%) patients with intracoronary thrombus, 5 (56%; 19% of entire group) had total occlusion. Thrombus occurred on a >50% stenosis (by cross-sectional area) in a total of 33% (95% CI 16%–55%) of patients. The only statistically significant difference in clinical variables between patients with and without plaque rupture was longer interval from surgery to death in patients with plaque rupture (7.8 ± 4.4 days versus 4.4 ± 4.8 days; p = 0.047). In this autopsy series, coronary plaque rupture was associated with almost half of fatal postoperative MI cases. Strategies aimed at reducing triggers of plaque rupture with coronary occlusion might reduce postoperative MI fatality.

Section snippets

Patients

To identify cases of postoperative MI, we reviewed a total of 1841 consecutive autopsy records at two institutions (Deaconess Hospital, January 1, 1988 to December 31, 1995, n = 894; and Lahey-Hitchcock Medical Center, January 1, 1981 to December 31, 1995, (n = 947). The study was approved by the Institutional Review Boards of both hospitals. We excluded patients who had not received general anesthesia and patients with a history of coronary artery bypass surgery or with postoperative MI

Results

We identified 26 patients (age 68 ± 13 years; 9 females) who had suffered a fatal postoperative MI whose coronary histology was available for review. All MIs appeared to be ⩽72 hours in age. Fatal MI complicated the following types of surgical procedures: general surgery (10), vascular surgery (9), thoracic surgery (4), orthopedic surgery (2), and neurosurgery (1). Surgery was elective in all but one case. Death occurred a mean of 6.0 ± 4.9 (range, 0 to 17) days after surgery. Within the entire

Discussion

In this study of patients with fatal postoperative MI, we identified signs of plaque rupture in nearly half of cases. The morphology of coronary lesions and incidence of plaque disruption that we observed is similar to previous studies of sudden cardiac ischemic death 1, 2, 3, 4, 6, 7 in which close serial sections of coronary arteries were examined. Thus, fatal postoperative MI may have similar pathophysiologic mechanisms of onset as MI not associated with surgery.

Our findings confirm those of

Conclusions

In this autopsy study, plaque rupture in coronary arteries was associated with almost half of fatal postoperative MI cases. Despite a relatively insensitive methodology, our results are consistent with the findings of other investigations of sudden ischemic cardiac deaths not associated with surgery. Further prospective investigations, including randomized controlled clinical trials, are necessary to define the mechanisms and optimal, cost-effective, preventive strategies for adverse

Acknowledgements

The authors thank Mark Silverman, Department of Pathology, Lahey-Hitchcock Medical, Burlington, Massachusetts, for his assistance, and Murray Mittleman and Richard Nesto, Cardiovascular Division, Beth Israel Deaconess Medical Center, for their careful, constructive criticism of the manuscript. M. C. Cohen was partially supported by Public Health Service Fellowship No. 1-F32-HL08912-01-PSF.

Presented at the 46th Annual Scientific Session of the American College of Cardiology, Anaheim, California,

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Perioperative myocardial infarction is frequently attributed to type 2 myocardial infarction, a mismatch in myocardial oxygen supply-demand without unstable coronary artery disease. Our aim was to identify characteristics, management, and outcomes of perioperative type 1 versus type 2 myocardial infarction among surgical inpatients.
Adults age ≥45 years hospitalized for noncardiac surgery were identified in the United States. Perioperative myocardial infarction were identified using International Classification of Diseases, 10th revision (ICD-10) codes. Clinical characteristics, invasive myocardial infarction management, mortality, and readmissions were assessed by myocardial infarction subtype.
Among 4,755,382 surgical hospitalizations, we identified 38,975 perioperative myocardial infarctions (0.82%), with type 2 infarction in 42%. Patients with type 2 myocardial infarction were older, more likely to be women, and less likely to have cardiovascular comorbidities compared with type 1 myocardial infarction. Fewer patients with type 2 myocardial infarction underwent invasive management than type 1 myocardial infarction (6.7% vs 28.8%, P < .001). Type 2 myocardial infarction mortality was lower than type 1 myocardial infarction mortality (12.1% vs 17.4%, P < .001; adjusted odds ratio [aOR] 0.51, 95% confidence interval [CI] 0.45-0.59). Invasive management of perioperative myocardial infarction was associated with lower mortality in type 1 (aOR 0.56, 95% CI 0.49-0.74) but not type 2 (aOR 1.19, 95% CI 0.77-1.85) myocardial infarction. Among survivors, there was no difference in 90-day hospital readmission between type 2 and type 1 perioperative myocardial infarction (36.5% vs 36.1%, P = .72).
Type 2 myocardial infarctions account for approximately 40% of perioperative myocardial infarctions. Patients with type 2 perioperative myocardial infarction are less likely to undergo invasive management and have lower mortality compared with those with type 1 perioperative myocardial infarction.
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Perioperative beta-blockade (PBB) has been advocated for the reduction of cardiac risk for noncardiac surgery, primarily through prevention of major adverse cardiac events (MACE). Nevertheless, the data and recommendations supporting PBB have been both changing and conflicting. Early interest in using beta-blockers to protect against perioperative cardiovascular complications was supported by a small number of randomized controlled trials (RCTs) and reviews, and beta-blockers were quickly adopted because their perceived benefit was considered large with few documented adverse effects. More recent data however, suggest that PBB may carry significantly increased risk for perioperative morbidity and mortality for many patients, particularly through increased risk for stroke and hypotension. This chapter aims to provide a review of the development of literature surrounding PBB, discuss the uncertainties surrounding PBB, and review the American and European guidelines surrounding use of beta-blockers during the perioperative period. A focus of this chapter is on recent updates in the literature and recommendations over the past decade.
Should Patients With Stable Coronary Artery Disease Undergo Prophylactic Revascularization Before Noncardiac Surgery?
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Factors to consider in estimating cardiac risk before an elective noncardiac operation include the nature of the operation, the risk for associated coronary artery disease, and the functional capacity of the patient. The initial evaluation requires an assessment of a prior history of cardiac problems or risk factors along with either classic angina or unusual symptoms such as shortness of breath or atypical chest pains. Clinical risk factors associated with increased risk include age greater than 70 years, angina, history of congestive heart failure, prior myocardial infarction, prior stroke or transient ischemic attack, history of ventricular arrhythmias, diabetes mellitus, and abnormal renal function. In those patients who are unable to achieve a 4-MET (metabolic equivalent of task) demand, a level compatible with routine daily activities, there is an increased risk for postoperative events, and additional testing may be warranted. Patients in need of a vascular operation have the highest risk. After risk stratification, the next step is to assess strategies to mitigate perioperative risk. Among patients undergoing elective vascular surgery, a strategy of preoperative coronary artery revascularization before elective vascular surgery does not improve outcome but rather may delay or even prevent the needed vascular procedure. Therefore coronary artery revascularization before elective vascular surgery among patients with stable ischemic heart disease is not recommended. To improve the outcomes of high-risk patients, we must shift the paradigm from widespread identification and treatment of coronary artery disease in the preoperative phase to a more comprehensive identification and modification of risk factors in the postoperative phase, including optimization of medical therapies.
Accuracy of Physicians in Differentiating Type 1 and Type 2 Myocardial Infarction Based on Clinical Information
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Physicians commonly judge whether a myocardial infarction (MI) is type 1 (thrombotic) vs type 2 (supply/demand mismatch) based on clinical information. Little is known about the accuracy of physicians’ clinical judgement in this regard. We aimed to determine the accuracy of physicians’ judgement in the classification of type 1 vs type 2 MI in perioperative and nonoperative settings.
We performed an online survey using cases from the Optical Coherence Tomographic Imaging of Thrombus (OPTIMUS) Study, which investigated the prevalence of a culprit lesion thrombus based on intracoronary optical coherence tomography (OCT) in patients experiencing MI. Four MI cases, 2 perioperative and 2 nonoperative, were selected randomly, stratified by etiology. Physicians were provided with the patient’s medical history, laboratory parameters, and electrocardiograms. Physicians did not have access to intracoronary OCT results. The primary outcome was the accuracy of physicians' judgement of MI etiology, measured as raw agreement between physicians and intracoronary OCT findings. Fleiss’ kappa and Gwet’s AC1 were calculated to correct for chance.
The response rate was 57% (308 of 536). Respondents were 62% male; median age was 45 years (standard deviation ± 11); 45% had been in practice for > 15 years. Respondents’ overall accuracy for MI etiology was 60% (95% confidence interval [CI] 57%-63%), including 63% (95% CI 60%-68%) for nonoperative cases, and 56% (95% CI 52%-60%) for perioperative cases. Overall chance-corrected agreement was poor (kappa = 0.05), consistent across specialties and clinical scenarios.
Physician accuracy in determining MI etiology based on clinical information is poor. Physicians should consider results from other testing, such as invasive coronary angiography, when determining MI etiology.
Les médecins déterminent généralement s’ils sont en présence d’un infarctus du myocarde (IM) de type 1 (thrombotique) ou de type 2 (demande accrue ou apport réduit en oxygène) sur la base des renseignements cliniques. On en sait cependant très peu au sujet de la justesse du jugement clinique des médecins à cet égard. Nous avons donc cherché à déterminer si les médecins réussissent à distinguer correctement les IM de type 1 et de type 2 dans les contextes périopératoire et non opératoire.
Nous avons mené une enquête en ligne en utilisant les cas de l’étude OPTIMUS (Optical Coherence Tomographic Imaging of Thrombus), qui avait évalué la prévalence des lésions causant un thrombus au moyen de la tomographie par cohérence optique (TCO) endocoronaire chez les patients subissant un IM. Nous avons choisi au hasard quatre cas d’IM stratifiés en fonction de leur cause : deux cas en contexte périopératoire et deux cas en contexte non opératoire. Les médecins avaient accès aux antécédents médicaux, aux résultats des analyses de laboratoire et aux électrocardiogrammes des patients, mais pas aux résultats de la TCO endocoronaire. Le principal paramètre d’évaluation était la justesse du jugement du médecin concernant la cause de l’IM, mesurée en fonction de la concordance approximative entre le jugement du médecin et les observations à la TCO endocoronaire. Les coefficients de concordance kappa de Fleiss et AC1 de Gwet ont servi à corriger pour le hasard.
Le taux de réponse était de 57 % (308 sur 536). Des participants, 62 % étaient des hommes et 45 % exerçaient depuis plus de 15 ans; l’âge médian était de 45 ans (écart-type : ± 11). La justesse globale avec laquelle les répondants ont déterminé la cause des IM était de 60 % (intervalle de confiance [IC] à 95 % : 57-63 %) : 63 % (IC à 95 % : 60-68 %) dans le cas des IM en contexte non opératoire et 56 % (IC à 95 % : 52-60 %) dans le cas des IM en contexte périopératoire. La concordance globale corrigée pour le hasard était faible (kappa = 0,05) et demeurait constante, sans égard au domaine de spécialité ou au scénario clinique.
La justesse du jugement des médecins évaluant la cause d’un IM en fonction des renseignements cliniques est faible. Les médecins devraient envisager de recourir à des tests additionnels, y compris la coronarographie invasive, avant de déterminer la cause d’un IM.
The Pathophysiology of Myocardial Ischemia and Perioperative Myocardial Infarction
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Ischemic heart disease, the leading cause of death worldwide, may result in devastating perioperative ischemia and infarction. The underlying pathophysiology, precipitating factors, and approach to prevention differ between patients presenting for noncardiac surgery, developing acute coronary syndrome versus stable angina. The first half of this article reviews the pathophysiology of acute coronary syndrome and stable angina. Acute coronary syndrome, otherwise known as Type 1 myocardial infarction, includes unstable angina, non-ST segment elevated myocardial infarction and ST segment elevated myocardial infarction. Acute coronary syndrome occurs as a result of vulnerable plaque rupture with subsequent varying degrees of thrombus formation, arterial spasm, and thus coronary occlusion. Stable angina, on the other hand, results from a myocardial oxygen delivery and demand mismatch in the setting of fixed coronary stenosis. After this discussion, the review article considers how both apply to perioperative myocardial infarctions and myocardial injury after noncardiac surgery. This article furthermore argues why myocardial oxygen delivery demand mismatch (Type 2) myocardial infarction is the most likely underlying pathophysiology responsible for perioperative myocardial infarctions. Being aware of this and knowledgeable about Type 2 infarctions may enable anesthetic providers to better predict the majority of triggers contributing to, and thus decreasing the incidence of, perioperative myocardial infarctions.
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ArticlesHistological Analysis of Coronary Artery Lesions in Fatal Postoperative Myocardial Infarction

Abstract

Section snippets

Patients

Results

Discussion

Conclusions

Acknowledgements

J Atheroscler Res

J Am Coll Cardiol

Chest

Int J Cardiol

J Clin Epidemiol

J Am Coll Cardiol

Lancet

J Clin Anesth

J Vasc Surg

Am J Cardiol

Am J Cardiol

Am J Med

Ann Thorac Surg

Lancet

Prog Cardiovasc Dis

Ann Vasc Surg

Am J Surg

Coronary thrombosis in pathogenesis of acute myocardial infarction. Histopathological study of coronary arteries in 108 necropsied cases using serial section

Br Heart J

Thrombosis and acute coronary-artery lesions in sudden cardiac ischemic death

N Engl J Med

Noncardiac surgery in the cardiac patientwhat is the question?

Ann Intern Med

Plaque rupture with severe pre-existing stenosis precipitating coronary thrombosis. Characteristics of coronary atherosclerotic plaques underlying fatal occlusive thrombi

Br Heart J

Coronary risk factors and plaque morphology in men with coronary disease who died suddenly

N Engl J Med

Myocardial infarction after general anesthesia

JAMA

Myocardial infarction in patients undergoing noncardiac surgery

Cleve Clin J Med

Correlation between preoperative ischemia and major cardiac events after peripheral vascular surgery

N Engl J Med

Articles
Histological Analysis of Coronary Artery Lesions in Fatal Postoperative Myocardial Infarction