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  • Review Article
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Therapy insight: prophylaxis, monitoring and treatment of perioperative myocardial ischemia with emphasis on urological surgery

Nature Clinical Practice Urology volume 4, pages 333–340 (2007)Cite this article

Abstract

Unrecognized or silent perioperative myocardial ischemia is common in patients who undergo high-risk surgery, including cystectomy, and could predict cardiac morbidity and mortality in postoperative patients. This disorder is not merely a marker of extensive coronary disease but has a close association with perioperative myocardial infarction (PMI). In a review of published data, including meta-analyses, in the context of high-risk urological surgery, up to 50% of PMIs were found to go unrecognized if only clinical signs and symptoms are considered. Prevention and treatment of these previously unrecognized cardiac events might significantly reduce long-term morbidity and mortality. The emergence of reliable markers of PMI, such as increased levels of troponin I, could help in the detection of events that would have otherwise remained unnoticed. In this Review we examine the effect of these developments in the context of high-risk urological surgery. Changes to preoperative assessment, perioperative management, and prophylaxis of PMI are critically assessed. We performed a prospective audit using postoperative troponin I levels to assess the rate of silent perioperative myocardial ischemia and infarction. An increasingly proactive attitude towards perioperative monitoring for myocardial ischemia and infarction has evolved, and postoperative serial screening with troponin I might be beneficial in high-risk patients undergoing major urological surgery.

Key Points

  • Perioperative myocardial ischemia is common in patients who undergo high-risk surgery, including cystectomy, and has a close association with postoperative myocardial infarction

  • Serial postoperative monitoring of troponin I currently has the highest diagnostic yield for postoperative myocardial infarction

  • In our study of patients who underwent cystectomy, 20% had elevated postoperative troponin I levels within 24 h of surgery

  • Currently, the management of perioperative myocardial infarction is modeled after the established and well-studied treatment of nonoperative myocardial infarction, although the two conditions might have different etiologies

  • An increasingly proactive attitude towards perioperative serial screening with troponin I has evolved, including for high-risk patients with urological conditions

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Author information

Authors and Affiliations

  1. and P Doyle is a Consultant Anesthetist in the Departments of Urology and Anesthetics at Charing Cross Hospital, MH Winkler is a Specialist Registrar in Urology, D Hrouda is a Consultant Urological Surgeon, London, UK.,

    Mathias H Winkler, David Hrouda & Patrick Doyle

  2. EK Mayer is a Urology Research Registrar at Imperial College, London.,

    Eric K Mayer

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  1. Mathias H Winkler
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  2. Eric K Mayer
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  3. David Hrouda
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  4. Patrick Doyle
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Correspondence to Mathias H Winkler.

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Winkler, M., Mayer, E., Hrouda, D. et al. Therapy insight: prophylaxis, monitoring and treatment of perioperative myocardial ischemia with emphasis on urological surgery. Nat Rev Urol 4, 333–340 (2007). https://doi.org/10.1038/ncpuro0817

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