Perioperative Myocardial Infarction Prevention
Beta-Blocker Therapy
- The American College of Cardiology recommends that patients already on beta-blockers must continue them throughout the perioperative period (Class I) 1, 2
- Withdrawal of beta-blockers increases 1-year mortality dramatically (HR: 2.7) compared to continuous use 2
- Postoperative discontinuation carries 50% mortality versus 1.5% with continuation 2
- Initiate bisoprolol 2.5-5 mg daily starting 7-30 days before surgery, and titrate to achieve resting heart rate 50-60 bpm preoperatively 3, 4, 5
- Maintain heart rate <70-80 bpm intraoperatively and postoperatively 6, 3, 4
- Long-acting formulations are superior to short-acting 6
- Starting beta-blocker therapy the day before surgery provides inadequate beta-blockade and may worsen outcomes 4
Statin Therapy
- The American Heart Association recommends that all patients currently taking statins must continue them perioperatively (Class I) 1, 2
- Withdrawal of statins >4 days postoperatively independently predicts myonecrosis 6
- Start statins for all patients undergoing vascular surgery regardless of risk factors (Class IIa) 1, 2
- Ideally initiate statins 30 days before surgery 1
- Statin therapy reduces mortality by 59% in vascular surgery (1.7% vs 6.1%) and by 44% across all noncardiac surgery (2.2% vs 3.2%) 1, 2
Antiplatelet Therapy Management
- Continue aspirin perioperatively for secondary prevention unless bleeding risk is very high (e.g., intracranial surgery)
- Dual antiplatelet therapy should continue in patients with recent coronary stents 7, 8
- Delay elective surgery: ≥14 days after balloon angioplasty, ≥30 days (4-6 weeks) after bare-metal stent, and ≥6-12 months after drug-eluting stent 7, 8
- Continue aspirin if possible in urgent surgery in stented patients (Class IIa) 7, 8
- Restart thienopyridine as soon as possible postoperatively in urgent surgery in stented patients (Class IIa) 7, 8