title: Angiographic investigation of the pathophysiology of perioperative myocardial infarction.
abstract: BACKGROUND
  The study of the pathophysiologic mechanism of perioperative myocardial infarctions is limited to two small autopsy studies suggesting a major role for plaque rupture and thrombosis. However, the perioperative period is characterized by increased cardiac metabolic demand that may lead to infarction in patients with otherwise stable obstructive coronary artery disease. The purpose of this study is to investigate the pathophysiology of perioperative myocardial infarctions.
  
  
  METHODS
  Hospital records and coronary angiograms from patients from 1998 to 2006 who underwent noncardiac surgery complicated by a perioperative myocardial infarction (MI) were reviewed. The culprit lesion was identified based on ECG, left ventriculography, and coronary angiography. Degree of stenosis, TIMI flow, ACC thrombus grade, calcification score, and lesion morphology were evaluated. Based on these criteria, MIs were categorized as thrombotic, demand, or nonobstructive.
  
  
  RESULTS
  Sixty-six patients (average age, 71 years and 44% male), 77% of whom underwent an intermediate risk surgery with a 2% perioperative mortality, were identified. The distribution of demand, thrombotic, and nonobstructive MI was 55%, 26%, and 19%, respectively. There was neither statistical difference in the occurrence of prolonged hypotension or tachycardia between groups nor was there any difference in the use of antiplatelets, β-blockers, or statins.
  
  
  CONCLUSIONS
  This study identified demand ischemia as the predominant etiology of perioperative MIs in this cohort. An improved understanding of the pathophysiologic mechanism of perioperative MIs may facilitate the evaluation and management of preoperative patients.
authors.affiliation: Department of Medicine, Mount Sinai Medical Center, New York, New York 10029, USA. william.duvall@msnyuhealth.org
authors.forename: W Lane
authors.initials: WL
authors.lastname: Duvall
authors.forename: Brett
authors.initials: B
authors.lastname: Sealove
authors.forename: Chetan
authors.initials: C
authors.lastname: Pungoti
authors.forename: Daniel
authors.initials: D
authors.lastname: Katz
authors.forename: Pedro
authors.initials: P
authors.lastname: Moreno
authors.forename: Michael
authors.initials: M
authors.lastname: Kim
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D001344:Autopsy; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D003328:Coronary Thrombosis / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology*; D059035:Perioperative Period; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D012422:Rupture, Spontaneous; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000401:mortality