Prevention of Myocardial Infarction in Patients Undergoing Non-Cardiac Surgery

Immediate Preoperative Medical Management

The American College of Cardiology recommends continuing statins perioperatively in all patients already taking them, and initiating statins in statin-naïve patients with atherosclerotic cardiovascular disease or elevated 10-year ASCVD risk who are undergoing vascular or elevated-risk surgery 1
Statin therapy reduces major adverse cardiac events (MACE) by approximately 60% in vascular surgery patients, with a composite endpoint reduced from 26% to 8% with atorvastatin 20 mg daily started 30 days preoperatively 1
The American College of Cardiology recommends continuing beta-blockers in patients already taking them, but not routinely initiating beta-blockers in beta-blocker-naïve patients, particularly within 1 day of surgery 1
Withdrawal of chronic beta-blockers increases 1-year mortality dramatically, with a hazard ratio of 2.7, and postoperative discontinuation carries 50% mortality versus 1.5% with continuation 1
The American Heart Association recommends continuing aspirin perioperatively for secondary prevention unless bleeding risk is extremely high, such as in intracranial surgery 1

The American College of Cardiology recommends identifying active cardiac conditions requiring evaluation and treatment before surgery, including unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease 3, 4
The American College of Cardiology recommends assessing functional capacity using metabolic equivalents (METs), with patients having excellent functional capacity (≥10 METs) able to proceed to surgery without further cardiac testing, even with elevated risk factors 5
The American College of Cardiology recommends stratifying surgical risk into high-risk, intermediate-risk, and low-risk surgery, with high-risk surgery including emergent major operations, aortic and major vascular surgery, and peripheral vascular surgery 6, 7

The American College of Cardiology recommends against routine prophylactic coronary revascularization before noncardiac surgery in patients with stable coronary artery disease, with coronary revascularization only indicated for standard indications independent of the planned surgery 5, 2, 1
The American College of Cardiology recommends coronary revascularization before noncardiac surgery in patients with significant left main coronary artery stenosis, 3-vessel disease, 2-vessel disease with significant proximal LAD stenosis, high-risk unstable angina, or non-ST-elevation MI 2

The American College of Cardiology recommends measuring troponin and obtaining ECG when signs or symptoms of ischemia, MI, or arrhythmia are present, with postoperative troponin measurement recommended in patients with ECG changes or chest pain typical of acute coronary syndrome 1, 9
The American College of Cardiology recommends against routine postoperative screening with troponin or ECG in asymptomatic high-risk patients, with uncertain benefit, and recommends against postoperative troponin measurement in asymptomatic stable patients who have undergone low-risk surgery 1, 4

The American College of Cardiology recommends standard medical therapy including aspirin, beta-blockers, ACE inhibitors, and high-intensity statin therapy immediately for all patients with perioperative MI, with aspirin initiated immediately and continued indefinitely unless bleeding risk is prohibitive 9
The American College of Cardiology recommends invasive coronary angiography for perioperative STEMI, carefully balancing bleeding and thrombotic risks, with angioplasty considered when symptomatic perioperative ST-segment elevation MI occurs due to sudden thrombotic occlusion 9, 10
The American College of Cardiology recommends focusing on correcting underlying causes such as hypotension, tachycardia, anemia, or hypertension for Type 2 MI, and evaluating left ventricular function before hospital discharge for all patients who sustain perioperative MI 9