An immediate invasive strategy for the treatment of acute myocardial infarction early after noncardiac surgery.

M from myocardial infarction (MI) early after noncardiac surgery ranges from 40% to 70%.1 The high mortality is multifactorial, in part from significant comorbidity. One contributor to the high mortality is the inability to administer thrombolytic therapy because of the risk of bleeding at the surgical site.2 Direct angioplasty also reduces mortality from MI and compares favorably with thrombolytic therapy.3 Because of the lower risk of bleeding associated with angioplasty, this procedure may be beneficial in the treatment of early postoperative MI; however, to our knowledge, there are no studies of direct angioplasty in such patients. Therefore, we studied the clinical course and outcome of patients at our institution undergoing immediate angiography for acute MI early after noncardiac surgery. • • • We analyzed the catheterization laboratory and surgical databases at Mayo Clinic between 1990 and 1998 and identified 48 consecutive patients referred for coronary angiography for acute MI within 7 days after noncardiac surgery. All patients had ischemictype chest pain for $30 minutes or hemodynamic instability with ischemic electrocardiographic changes. Cardiogenic shock was defined as systolic blood pressure ,90 mm Hg for .1 hour unresponsive to fluid. Successful angioplasty was defined as a reduction in stenosis of $20% and a residual stenosis ,50% by visual estimation. The baseline clinical characteristics of the study population, preoperative tests performed, and medications at the time of admission are listed in Table 1. Types of surgical procedures included the following: intraabdominal, 14 patients; orthopedic, 11; vascular, 11; urologic, 5; neurologic, 3; and other types, 4. Intraoperative instability was present in 5 patients. Thirty-three patients had ST-segment elevation (anterior in 14), 8 had ST-segment depression, 4 had a new bundle branch block, and 3 had other changes. The median duration between surgery and symptom onset was 1 day (mean 1.6 6 1.9), and from symptom onset to coronary angiography, 4 hours (mean 11.1 6 17.4). Shock was present in 21 patients, and cardiac arrest occurred in 12 before angiography. Angiography revealed 1-vessel disease in 6 and multivessel disease in 42. The infarct artery was the left anterior descending in 18 patients, right coronary in 15, circumflex in 7, left main in 1, and a vein graft in 2. The infarct artery could not be determined in 5 patients; 1 had anterior ST elevation and 70% stenosis in all 3 coronary arteries but no occlusion or thrombus on angiography. The other 4 each had what appeared to be several chronically occluded vessels. The infarct artery was partially or totally occluded in 32 patients; there was evidence of thrombus in 30. Of 41 patients who underwent angioplasty (Figure 1), the procedure was successful in 30, 6 of whom had stent placement. Three patients underwent bypass surgery: of those, 2 had surgery immediately after angiography, 1 of whom developed severe papillary muscle dysfunction and also underwent mitral valve From the Division of Cardiovascular Diseases and Internal Medicine, the Department of Anesthesiology, and the Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Dr. Berger’s address is: Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905. E-mail: berger.peter@mayo.edu. Manuscript received October 12, 2000; revised manuscript received and accepted November 21, 2000. TABLE 1 Baseline Characteristics (n 5 48)