Sometimes a paper comes along that breaks my brain. This is one of those research studies which is in the form of a position paper published by the American Heart Association. It basically says that some people are getting heart damage during routine surgery. So let’s dig in because when I first read it yesterday, all I could say was “Wow”.
Things You Need to Know to Understand this Study
When someone has a heart attack, the heart muscle is damaged and there is a blood test that detects a muscle breakdown protein called troponin. Hence, if you go into an emergency room with chest pain and they think you’re having a heart attack, the first thing that they will do is to get an EKG. If that looks at all suspicious, the next thing they will do is to check your serum troponin levels. If that’s detected beyond a certain amount, then that nails the diagnosis of a heart attack.
The New American Heart Association Position Statement
What’s mind-blowing about the new American Heart Association position statement is that it’s a review of many other studies that all point towards routine surgeries in some patients causing asymptomatic heart damage. To come to this conclusion, many of these studies measured troponin levels and found evidence of higher levels after surgery that were then related to a later elevated risk of severe heart problems after the surgery. These patients generally had no symptoms. When I read that, my head exploded, as this is not just a theory and single study, but strong enough evidence from many large studies that the world’s most powerful organization in the cardiac space is putting out a warning to other doctors.
What Is this New Syndrome Called?
The AHA calls this MINS or myocardial injury after noncardiac surgery (1). That basically means that someone who was undergoing some surgery outside of heart surgery gets heart damage. What causes this to happen? Lots of things like:
- Low or high blood pressure during surgery
- A blood clot caused by surgery
- Very low or very high heart rate during surgery
- Anemia
- Extensive tissue damage caused by surgery that causes a severe inflammatory response
- A prior history of cardiac issues or other diseases (the fragile egg problem)
Who Is Most at Risk?
Here’s the list of risk factors of who is the most likely to suffer from MINS:
- Elderly over young
- Males over females
- Low functioning patients (i.e. not active)
- High blood pressure
- Diabetes
- Known prior heart disease
- Peripheral artery disease
- Known heart valve disease (i.e. mitral valve prolapse)
- Chronic Heart Failure
- Afib
- Kidney disease
- Sleep apnea
MINS is worse in emergency surgery. However, this is the list of routine surgeries that are also know to be associated with a higher risk of MINS. In the VISION study, the highest incidence of myocardial injury followed (2):
- Vascular (19%)
- Orthopedic (12%)
- Thoracic (9%)
- General (9%) surgeries.
What Kind of Orthopedic Surgery?
The biggest question for my readers is what kind of orthopedic surgery is associated with MINS? The answer, once I looked it up at the US National Library of Medicine, also blew my mind. This is from that same VISION study looking specifically at orthopedic surgery (3):
“One in 8 orthopedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms.”
Yikes! In addition, 81% of these patients would have gone undetected as having MINS if not for the routine troponin testing performed for this study. If you had elevated troponin levels after surgery, your likelihood was nine times greater of dying within 30 days after the surgery.
What Does All of This Mean?
I can’t stress enough what a big deal MINS is at this point. If 1 in 8 people have had heart damage after orthopedic surgery, that means a few different things that will immediately need to change:
- Being much more cautious about who we recommend for surgery. Meaning anyone who has one or more of the risk factors above MUST be notified of this risk before the procedure using expanded informed consent. That means that it’s not enough to include a risk of MINS on a consent form buried in the legalese, you must verbally discuss it with each and every patient and document that you had that discussion.
- Reducing the exposure to surgery where possible. Meaning at this point, every patient should exhaust all non-surgical options. This is doubly true for anyone with the listed risk factors.
- A move towards smaller and smaller surgical procedures as MINS is linked to the degree of tissue damage during surgery.
- Changes in the way anesthesiologists look at perfusion during surgery.
- Routine troponin levels before and after all orthopedic surgeries.
The upshot? Wow, this position statement is still blowing my mind based on how much this finding will change the orthopedic surgery world. Please read this blog carefully and if you’re considering orthopedic surgery, discuss MINS with your treating physician.
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References:
(1) Ruetzler K, Smilowitz NR, Berger JS, Devereaux PJ, Maron BA, Newby LK, de Jesus Perez V, Sessler DI, Wijeysundera DN; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation; Council on Clinical Cardiology; and Council on Cardiovascular Surgery and Anesthesia. Diagnosis and Management of Patients With Myocardial Injury After Noncardiac Surgery: A Scientific Statement From the American Heart Association. Circulation. 2021 Oct 4:CIR0000000000001024. doi: 10.1161/CIR.0000000000001024. Epub ahead of print. PMID: 34601955.
(2) Vascular Events in Noncardiac Surgery Patients Cohort Evaluation Study Investigators, Devereaux PJ, Chan MT, Alonso-Coello P, Walsh M, Berwanger O, Villar JC, Wang CY, Garutti RI, Jacka MJ, Sigamani A, et al. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307:2295–2304. doi: 10.1001/jama.2012.5502
(3) Thomas S, Borges F, Bhandari M, De Beer J, Urrútia Cuchí G, Adili A, Winemaker M, Avram V, Chan MTV, Lamas C, Cruz P, Aguilera X, Garutti I, Alonso-Coello P, Villar JC, Jacka M, Wang CY, Berwanger O, Chow C, Srinathan S, Pettit S, Heels-Ansdell D, Rubery P, Devereaux PJ; VISION Investigators. Association Between Myocardial Injury and Cardiovascular Outcomes of Orthopaedic Surgery: A Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Substudy. J Bone Joint Surg Am. 2020 May 20;102(10):880-888. doi: 10.2106/JBJS.18.01305. PMID: 32118652.
