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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EMost postoperative myocardial infarctions are detected as asymptomatic elevated troponin. Aspirin appears ineffective in preventing postoperative myocardial infarction following noncardiac surgery, but it may have a protective role before surgery. Antithrombotic therapy may be used for persistent paroxysmal atrial fibrillation, with attention paid to the risks of stroke and bleeding.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Earrhythmias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eatrial fibrillation\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Easpirin\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiology \u0026amp; cardiovascular medicine screening \u0026amp; prevention\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Emyocardial infarction POISE\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eperioperative complications\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003ESome 230 million noncardiac surgeries are done annually, about 10 million of which are complicated by major cardiovascular events, including myocardial infarction (MI), within 30 days of surgery.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThirty years ago, preventable anesthetic-related mortality was about 1 in 10\u2005000 patients. Now, according to Daniel I. Sessler, MD, Cleveland Clinic, Cleveland, Ohio, USA, it is \u0026lt;\u20051 in 100\u2005000 patients. Despite this significant improvement, mortality remains high after patients leave the operating theater. The majority of 1-year postoperative deaths are typically due to preexisting cancer, and the mortality rate remains at about 5% overall and 10% in patients \u0026gt;\u200565 years old. In contrast, 30-day postoperative mortality is 2% for American inpatients aged \u2265\u200545 years and is largely due to MI and subsequent complications, with 80% of the deaths occurring during the initial hospitalization. If the postoperative period was regarded as a disease, it would rank as the third-leading cause of death in the United States [Bartels K et al. \u003Cem\u003EAnesthesiology\u003C\/em\u003E. 2013].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EThe majority of postoperative MIs are clinically silent. In the international prospective VISION cohort study of \u0026gt;\u200515\u2005000 patients undergoing surgery, most postoperative MIs were detected only by elevated troponin (\u003Ca id=\u0022xref-table-wrap-1-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T1\u0022\u003ETable 1\u003C\/a\u003E) [Devereaux PJ et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2012; Botto F et al. \u003Cem\u003EAnesthesiology\u003C\/em\u003E. 2014].\u003C\/p\u003E\u003Cdiv id=\u0022T1\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16833\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16833\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16833\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 1.\u003C\/span\u003E \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003ETroponin T Predicts Mortality\u003Csup\u003E\u003Csup\u003Ea\u003C\/sup\u003E\u003C\/sup\u003E\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-8\u0022\u003ETroponin elevations \u0026gt;\u20050.3 ng\/mL also increase the risk of nonfatal cardiac arrest, congestive heart failure, stoke, and death. According to an expert consensus document from the European Society of Cardiology, American College of Cardiology Foundation, American Heart Association, and World Heart Federation, routine monitoring of cardiac biomarkers such as troponin after major surgery has been recommended [Thygeson K et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2012]. While it is tempting to think that silent troponin elevation is less serious than symptomatic infarctions, the mortality is identical with silent and symptomatic troponin elevations; therefore, each event needs to be taken seriously.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EIf the majority of postoperative MIs are clinically silent, can they be prevented? The first intervention that the investigators evaluated for general anesthesia was avoidance nitrous oxide. However, results from the 7000-patient ENIGMA-II trial clearly indicate that nitrous oxide does not worsen risk of cardiovascular complications after noncardiac surgery [Myles PS et al. \u003Cem\u003ELancet\u003C\/em\u003E. 2014]. A previous study, the 8351-patient POISE-1 trial, showed that \u03b2-blockers reduced perioperative MI risk but at the cost of an increased risk of stroke [POISE Study Group. \u003Cem\u003ELancet\u003C\/em\u003E. 2008].\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EPlatelet activation and the resulting thrombosis may be the reason for perioperative MI, according to Philip J. Devereaux, MD, PhD, McMaster University, Hamilton, Ontario, Canada, who discussed the follow-up POISE-2 trial in more detail [Devereaux PJ et al. \u003Cem\u003ENew Engl J Med\u003C\/em\u003E. 2014]. The randomized 2 \u00d7 2 factorial design trial evaluated the use of aspirin and\/or clonidine to reduce perioperative cardiovascular events after noncardiac surgery. It involved more than 10\u2005000 patients undergoing noncardiac surgery (orthopedic, 39%; general, 27%; urologic\/gynecologic, 17%; vascular\/other, 15%) at risk of vascular complications. Of the 10\u2005010 randomized patients, 5628 were aspirin na\u00efve, and 4382 were chronic aspirin users. The latter halted aspirin use at a median of 7 days prior to surgery. Patients were randomized to receive aspirin or placebo just prior to surgery and then daily postoperatively\u201430 days for aspirin-na\u00efve patients and 7 days for chronic aspirin users. Clonidine\/placebo was initiated and continued 72 hours postoperatively. Regular aspirin therapy resumed after study treatment in chronic aspirin users [Devereaux PJ et al. \u003Cem\u003ENew Engl J Med\u003C\/em\u003E. 2014].\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003ENo differences were evident in primary or secondary outcomes between aspirin- and placebo-treated patients (\u003Ca id=\u0022xref-table-wrap-2-1\u0022 class=\u0022xref-table\u0022 href=\u0022#T2\u0022\u003ETable 2\u003C\/a\u003E). There was an increased risk of acute kidney injury requiring dialysis in the aspirin- vs placebo-treated patients (HR, 1.75; 95% CI, 1.00 to 3.09). The risk of major bleeding was increased with the use of aspirin over placebo (HR, 1.23; 95% CI, 0.04), with the risk decreasing over time. Life-threatening bleeding and stroke were not significantly different in the aspirin and placebo groups. Primary outcomes were similar between the aspirin-na\u00efve patients and chronic aspirin patients (HR, 0.99; 95% CI, 0.81 to 1.21; vs HR, 1.00; 95% CI, 0.81 to 1.23; \u003Cem\u003EP\u003C\/em\u003E\u003Csub\u003EInteraction\u003C\/sub\u003E\u2005=\u2005.96). Life-threatening bleeding and major bleeding independently predicted perioperative MI (HR, 1.82; 95% CI, 1.40 to 2.36; \u003Cem\u003EP\u003C\/em\u003E\u2005\u0026lt;\u2005.001).\u003C\/p\u003E\u003Cdiv id=\u0022T2\u0022 class=\u0022table pos-float\u0022\u003E\u003Cdiv class=\u0022table-inline\u0022\u003E\u003Cdiv class=\u0022callout\u0022\u003E\u003Cspan\u003EView this table:\u003C\/span\u003E\u003Cul class=\u0022callout-links\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022\/\u0022 class=\u0022table-expand-inline\u0022 data-table-url=\u0022\/highwire\/markup\/16834\/expansion?postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media%2Chighwire_embed\u0026amp;table-expand-inline=1\u0022 html=\u00221\u0022 fragment=\u0022#\u0022 external=\u00221\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView inline\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022\/highwire\/markup\/16834\/expansion?width=1000\u0026amp;height=500\u0026amp;iframe=true\u0026amp;postprocessors=highwire_figures%2Chighwire_math%2Chighwire_inline_linked_media\u0022 class=\u0022colorbox colorbox-load table-expand-popup\u0022 rel=\u0022gallery-fragment-tables\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView popup\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/16834\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022table-caption\u0022\u003E\u003Cspan class=\u0022table-label\u0022\u003ETable 2.\u003C\/span\u003E \u003Cp id=\u0022p-12\u0022 class=\u0022first-child\u0022\u003E30-Day Primary, Secondary, and Tertiary Outcomes for Aspirin\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-17\u0022\u003EWhile aspirin to prevent MI following noncardiac surgery appears groundless, a preventive role prior to surgery\u2014when the risk of bleeding is lower and the risk of thrombosis is higher\u2014may still have merit. Withholding aspirin in patients having noncardiac surgery to reduce perioperative complications may be helpful, with patients suffering perioperative MI perhaps benefiting from aspirin in both the short and long term.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EAs discussed by Pablo Alonso-Coello, MD, Institute of Biomedical Research, Barcelona, Spain, paroxysmal atrial fibrillation (AF) is the most common perioperative arrhythmia.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EThe incidence of perioperative AF is \u0026gt;\u200525% in cardiac surgeries and is particularly common following cardiac bypass and valvular surgery. The incidence is lower in noncardiac surgeries, but the magnitude of the problem is larger given the higher number of patients undergoing these procedures. While spontaneous conversion to normal rhythm usually occurs, postoperative AF can result in thromboembolic events.\u003C\/p\u003E\u003Cp id=\u0022p-20\u0022\u003EIn the POISE-1 trial [POISE Study Group. \u003Cem\u003ELancet\u003C\/em\u003E. 2008], perioperative AF was associated with increased 30-day postoperative risk of MI (HR, 5.34; 95% CI, 3.94 to 7.23), stroke (HR, 4.35; 95% CI, 1.87 to 10.12), congestive heart failure (HR, 6.55; 95% CI, 4.73 to 9.07), cardiac arrest (HR, 8.43; 95% CI, 3.73 to 19.05), and death (HR, 3.63; 95% CI, 2.27 to 5.81).\u003C\/p\u003E\u003Cp id=\u0022p-21\u0022\u003EAt 1 year after hospitalization, stroke due to perioperative AF is the major complication of noncardiac surgery (HR, 2147; 95% CI, 1.24 to 1.75) and cardiac surgery (HR, 0.99; 95% CI, 0.81 to 1.20) [Gialdini G et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2014].\u003C\/p\u003E\u003Cp id=\u0022p-22\u0022\u003EPrevention of AF in noncardiac surgery involves avoidance of triggers such as hypoxia and cardiac ischemia [Fauchier L et al. \u003Cem\u003ECurr Opin Cardiol\u003C\/em\u003E. 2013; Imazio M et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2011; POISE Study Group. \u003Cem\u003ELancet\u003C\/em\u003E. 2008]. Preventive factors in cardiac surgery include perioperative \u03b2-blockers, calcium channel blockers, amiodarone, and statins [\u003Cem\u003ECochrane Database Syst Rev\u003C\/em\u003E. 2013; Echahidi N et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2008].\u003C\/p\u003E\u003Cp id=\u0022p-23\u0022\u003EManagement strategies of perioperative AF involve treatment of an identifiable precipitant, electrical\/pharmacologic cardioversion, and, for persistent AF, control of heart rate. Antithrombotic therapy can be considered for AF persistent over 48 hours, with attention paid to the risks of stroke and bleeding [Devereaux PJ et al. \u003Cem\u003ENew Engl J Med\u003C\/em\u003E. 2014; Whitlock R et al. \u003Cem\u003ECan Med Assoc J\u003C\/em\u003E. 2014]. Long-term consequences of paroxysmal perioperative AF remain unclear.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/21\/17.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlglq\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_tables.js?nzlglq\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}