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Myocardial Injury After Noncardiac Surgery

A Systematic Review and Meta-Analysis

Smilowitz, Nathaniel R. MD*; Redel-Traub, Gabriel BS*; Hausvater, Anais MD*; Armanious, Andrew MD*; Nicholson, Joseph MS; Puelacher, Christian MD, PhD; Berger, Jeffrey S. MD, MS*,§,¶

doi: 10.1097/CRD.0000000000000254
Review Articles

Myocardial injury after noncardiac surgery (MINS) is a common postoperative complication associated with adverse cardiovascular outcomes. The purpose of this systematic review was to determine the incidence, clinical features, pathogenesis, management, and outcomes of MINS. We searched PubMed, Embase, Central and Web of Science databases for studies reporting the incidence, clinical features, and prognosis of MINS. Data analysis was performed with a mixed-methods approach, with quantitative analysis of meta-analytic methods for incidence, management, and outcomes, and a qualitative synthesis of the literature to determine associated preoperative factors and MINS pathogenesis. A total of 195 studies met study inclusion criteria. Among 169 studies reporting outcomes of 530,867 surgeries, the pooled incidence of MINS was 17.9% [95% confidence interval (CI), 16.2–19.6%]. Patients with MINS were older, more frequently men, and more likely to have cardiovascular risk factors and known coronary artery disease. Postoperative mortality was higher among patients with MINS than those without MINS, both in-hospital (8.1%, 95% CI, 4.4–12.7% vs 0.4%, 95% CI, 0.2–0.7%; relative risk 8.3, 95% CI, 4.2–16.6, P < 0.001) and at 1-year after surgery (20.6%, 95% CI, 15.9–25.7% vs 5.1%, 95% CI, 3.2–7.4%; relative risk 4.1, 95% CI, 3.0–5.6, P < 0.001). Few studies reported mechanisms of MINS or the medical treatment provided. In conclusion, MINS occurs frequently in clinical practice, is most common in patients with cardiovascular disease and its risk factors, and is associated with increased short- and long-term mortality. Additional investigation is needed to define strategies to prevent MINS and treat patients with this diagnosis.

From the *Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY

Department of Library Sciences, New York University School of Medicine, New York, NY

Department of Cardiology and Cardiovascular Research Institute Basel, University of Basel, Basel, Switzerland

§Division of Hematology, Department of Medicine, New York University School of Medicine, New York, NY

Division of Vascular Surgery, Department of Surgery, New York University School of Medicine, New York, NY.

Disclosure: Dr. J.S.B. was partially funded by the National Heart and Lung Blood Institute of the National Institutes of Health (HL114978), American Heart Association Clinical Research Program (13CRP14410042), and Doris Duke Charitable Foundation (2010055). Dr. N.R.S. was supported by the National Institutes of Health National Heart, Lung, and Blood Institute under award T32HL098129. He affirms that the manuscript is an honest, accurate, and transparent account of the study being reported. The other authors have no conflicts of interest to disclose.

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Correspondence: Nathaniel R. Smilowitz, MD, FACC, FSCAI, Leon H. Charney Division of Cardiology, New York University School of Medicine, 530 First Avenue, HCC-14, New York, NY 10016. E-mail:

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