A Project to Improve the Diagnosis and Prognosis of Myocardial Injury Associated to Non Cardiac Surgery

Study Overview
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Brief Summary
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Major adverse cardiovascular events are the leading cause of perioperative morbimortality in non-cardiac surgery. Perioperative myocardial infarction is usually asymptomatic, with a mortality around 10-12%. Myocardial Injury in Noncardiac Surgery (MINS), is defined as a myocardial injury that provokes a troponin increase due to myocardial ischemia. MINS is a predictor of morbimortality at short term and at long term. The aim of the study is to improve the diagnosis of myocardial injury after non cardiac surgery in high-risk patients, improve its treatment in case of MINS and establish prevention strategies.

Official Title
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A Project to Improve the Diagnosis and Prognosis of Myocardial Injury Associated to Non Cardiac Surgery

Conditions
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Myocardium; Injury

Intervention / Treatment
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* Diagnostic Test: Troponin
* Drug: Acetylsalicylic acid
* Drug: Statin


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients of both genders over 45 years scheduled for non-urgent surgery with in-hospital stay of 24 hours minimum who require general and or regional anaesthesia (epidural or subarachnoidal) that have signed the inform consent who will be operated of: 1. High-risk surgery: Open abdominal aortic aneurism repair Major vascular surgery Major amputations Carotid endarterectomy Duodeno-pancreatic surgery Hepatic resection or resection of biliary duct Esophagectomy Suprarenal resection Cystectomy Pneumonectomy 2. Medium risk-surgery with cardiovascular risk factors (see below): Intraperitoneal surgery (rectum, colon, small bowel, gastric surgery) Peripherical angioplasty Endovascular aneurism repair Head and neck surgery Major orthopedic surgery (hip, knee, column) Major urological or gynecological surgery Thoracic surgery (lobectomy or atypical pulmonary resections) a) With 1 risk factor: History of coronary artery disease History of cerebrovascular disease (history of transient ischemic attack or stroke) History of congestive heart failure History of vascular disease b) With 2 risk factors: Diabetes mellitus with medical treatment Renal disease (FGE < 45 ml•min-1•1.73m2 ) Functional capacity < 4METs Intraoperative blood loss >600ml Exclusion Criteria: Patients without consent information Patients non included in the inclusion criteria

Ages Eligible for Study
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Minimum Age: 45 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Non cardiac surgery<br>Determine perioperative troponin to diagnose perioperative MINS. In case of MINS acetylsalicylic acid and statins will be started if no contraindication. We will follow-up these patients for a year (including cardiologic evaluation after discharge) | Diagnostic Test: Troponin<br>* Troponin will be measured before surgery and postoperative at days 1,2 and 3.<br>Drug: Acetylsalicylic acid<br>* 100mg acetylsalicylic acid will be started in case of MINS if no contraindication, it will be continued after hospital discharge. We will evaluate cardiovascular complications till 1 year after surgery<br>Drug: Statin<br>* 40mg atorvastatin will be started in case of MINS if no contraindication, it will be continued after hospital discharge. We will evaluate cardiovascular complications till 1 year after surgery<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Prevalence of myocardial injury after non cardiac surgery (MINS). | The aim of the study is to know the prevalence of myocardial injury after non cardiac surgery in high-risk surgical patients. The investigators will perform seriated troponin on the first 3 postoperative days, if troponin value are 30ng/L or more, the investigators will evaluate if troponin increase is due to cardiac or non-cardiac etiology (patients with TEP or sepsis will be excluded). Once the non-cardiac etiology is ruled out, it will be diagnosed of MINS | From the day of surgery until the third postoperative day | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Percentage of MINS which corresponds to myocardial infarction | Evaluate the percentage of MINS that corresponds to myocardial infarction. In all patients with the diagnosis of MINS the investigators will perform an ECG to evaluate ischemic changes, an echocardiogram to evaluate dyskinesias or akinesia or the presence of ischemic symptoms. If any of them are present, the investigators will diagnose the patient of acute myocardial infarction. So the investigators will compare number of patients who present a MINS with and without myocardial infarction. | From the day of surgery until the third postoperative day | 
| Morbimortality in high-risk surgery patients until hospital discharge | Analyze morbimortality at hospital discharge of all patients included in the study. | From the day of surgery until hospital discharge or until 30 days after surgery in case the patient still hospitalized | 
| Compare the prognosis of patients with MINS versus patients who present a myocardial infarction versus who presented non of them. | To compare short and long term prognosis (hospital discharge, 30 days, 6 months and 1 year after surgery) of patients who presented MINS vs patients who presented myocardial infarction vs patients who did not presented any of them. The investigators will evaluate major cardiovascular events, non-cardiovascular complications and cardiac and all cause mortality. | From the day of surgery until 1 year after surgery | 
| Morbimortality in high-risk surgery patients 30 days after surgery | Analyze morbimortality at 30 days of all patients included in the study | From the day of surgery until 30 days after surgery | 
| Morbimortality in high-risk surgery patients 6 months after surgery | Analyze morbimortality at 6 postoperative months of all patients included in the study | From the day of surgery until 6 months after surgery | 
| Long term morbimortality in high-risk surgery patients | Analyze morbimortality of all patients included in the study 1 year after surgery | From the day of surgery until 1 year after surgery |