Infarto de Miocardio Tipo 2 en el Perioperatorio: Fisiopatología, Diagnóstico y Manejo Interdisciplinario
Resumen
Introducción: El infarto de miocardio tipo 2 (IM2) perioperatorio representa una complicación cardiovascular frecuente y subdiagnosticada en cirugía no cardíaca, asociada a morbimortalidad significativa. A diferencia del infarto tipo 1, el IM2 resulta de un desbalance entre el aporte y la demanda miocárdica de oxígeno, sin ruptura de placa aterosclerótica. Métodos: Se realizó una búsqueda estructurada en PubMed, MEDLINE, Cochrane Library y Google Scholar utilizando términos MeSH relacionados con infarto tipo 2, lesión miocárdica perioperatoria y troponinas. Se priorizaron guías de práctica clínica, metaanálisis y ensayos clínicos aleatorizados publicados entre 2018 y 2025. Resultados: La Cuarta Definición Universal de Infarto de Miocardio establece criterios específicos para el IM2. La incidencia de lesión miocárdica tras cirugía no cardíaca (MINS) oscila entre 8-20%. El 80% de los eventos ocurren en las primeras 48-72 horas postoperatorias. El manejo incluye optimización hemodinámica, estatinas, betabloqueadores y antiagregación individualizada. Conclusiones: El IM2 perioperatorio constituye una entidad clínica distinta al infarto tipo 1. La vigilancia sistemática de troponinas en pacientes de alto riesgo y el manejo multidisciplinario son fundamentales para reducir la morbimortalidad asociada
Descargas
Citas
Weiser TG, Haynes AB, Molina G, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015;385 Suppl 2:S11.
Devereaux PJ, Biccard BM, Sigamani A, et al. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery. JAMA. 2017;317(16):1642-1651.
Smilowitz NR, Berger JS. Perioperative Cardiovascular Risk Assessment and Management for Noncardiac Surgery: A Review. JAMA. 2020;324(3):279-290.
Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2014;64(22):e77-e137.
Smilowitz NR, Gupta N, Ramakrishna H, Guo Y, Berger JS, Bangalore S. Perioperative major adverse cardiovascular and cerebrovascular events associated with noncardiac surgery. JAMA Cardiol. 2017;2(2):181-187.
Botto F, Alonso-Coello P, Chan MT, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014;120(3):564-578.
Thygesen K, Alpert JS, Jaffe AS, et al. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018;72(18):2231-2264.
DeFilippis AP, Chapman AR, Mills NL, et al. Assessment and Treatment of Patients With Type 2 Myocardial Infarction and Acute Nonischemic Myocardial Injury. Circulation. 2019;140(20):2148-2168.
Chapman AR, Shah ASV, Lee KK, et al. Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury. Circulation. 2018;137(12):1236-1245.
Gualandro DM, Campos CA, Calderaro D, et al. Coronary plaque rupture in patients with myocardial infarction after noncardiac surgery: frequent and dangerous. Atherosclerosis. 2012;222(1):191-195.
Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009;119(22):2936-2944.
Priebe HJ. Triggers of perioperative myocardial ischaemia and infarction. Br J Anaesth. 2004;93(1):9-20.
Devereaux PJ, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med. 2011;154(8):523-528.
Puelacher C, Lurati Buse G, Seeberger D, et al. Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization. Circulation. 2018;137(12):1221-1232.
Writing Committee for the VISION Study Investigators. Association of Postoperative High-Sensitivity Troponin Levels With Myocardial Injury and 30-Day Mortality. JAMA. 2017;317(16):1642-1651.
Kavsak PA, Walsh M, Srinathan S, et al. High sensitivity troponin T concentrations in patients undergoing noncardiac surgery: a prospective cohort study. Clin Biochem. 2011;44(12):1021-1024.
VISION Study Investigators. Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery. JAMA. 2012;307(21):2295-2304.
van Waes JA, Nathoe HH, de Graaff JC, et al. Myocardial injury after noncardiac surgery and its association with short-term mortality. Circulation. 2013;127(23):2264-2271.
Sandoval Y, Thygesen K. Myocardial Infarction Type 2 and Myocardial Injury. Clin Chem. 2017;63(1):101-107.
Sandoval Y, Smith SW, Thordsen SE, Apple FS. Supply/demand type 2 myocardial infarction: should we be paying more attention? J Am Coll Cardiol. 2014;63(20):2079-2087.
Sarkisian L, Saaby L, Poulsen TS, et al. Clinical Characteristics and Outcomes of Patients with Myocardial Infarction, Myocardial Injury, and Nonelevated Troponins. Am J Med. 2016;129(4):446.e5-446.e21.
Nagele P, Brown F, Engel J, et al. High-sensitivity cardiac troponin T in prediction and diagnosis of myocardial infarction and long-term mortality after noncardiac surgery. Am Heart J. 2013;166(2):325-332.e1.
Sheth T, Natarajan MK, Gao P, et al. Coronary thrombus and adverse outcomes with non-cardiac surgery. Eur Heart J Qual Care Clin Outcomes. 2020;6(2):114-120.
Beattie WS, Karkouti K, Tait G, et al. Use of clinically based troponin underestimates the cardiac injury in non-cardiac surgery. Can J Anaesth. 2012;59(11):1013-1022.
Biccard BM, Scott DJA, Chan MTV, et al. Myocardial Injury After Noncardiac Surgery (MINS) in Vascular Surgical Patients. Ann Surg. 2018;268(2):357-363.
Sessler DI, Khanna AK. Perioperative myocardial injury and the contribution of hypotension. Intensive Care Med. 2018;44(6):811-822.
Salmasi V, Maheshwari K, Yang D, et al. Relationship between Intraoperative Hypotension, Defined by Either Reduction from Baseline or Absolute Thresholds, and Acute Kidney and Myocardial Injury. Anesthesiology. 2017;126(1):47-65.
Desborough JP. The stress response to trauma and surgery. Br J Anaesth. 2000;85(1):109-117.
Levy JH, Tanaka KA. Inflammatory response to cardiopulmonary bypass. Ann Thorac Surg. 2003;75(2):S715-S720.
Levi M, van der Poll T, Büller HR. Bidirectional relation between inflammation and coagulation. Circulation. 2004;109(22):2698-2704.
Mair J, Lindahl B, Hammarsten O, et al. How is cardiac troponin released from injured myocardium? Eur Heart J Acute Cardiovasc Care. 2018;7(6):553-560.
Ujueta F, Berger JS, Smilowitz N. Coronary angiography in patients with perioperative myocardial injury after non-cardiac surgery. J Invasive Cardiol. 2018;30(3):E90-E92.
Sheth T, Chan M, Butler C, et al. Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study. BMJ. 2015;350:h1907.
Duvall WL, Sealove B, Pungoti C, Katz D, Moreno P, Kim M. Angiographic investigation of the pathophysiology of perioperative myocardial infarction. Catheter Cardiovasc Interv. 2012;80(5):768-776.
McCarthy CP, Raber I, Chapman AR, et al. Myocardial Injury in the Era of High-Sensitivity Cardiac Troponin Assays: A Practical Approach for Clinicians. JAMA Cardiol. 2019;4(10):1034-1042.
Apple FS, Sandoval Y, Jaffe AS, Ordonez-Llanos J. Cardiac troponin assays: guide to understanding analytical characteristics and their impact on clinical care. Clin Chem. 2017;63(1):73-81.
Reed GW, Rossi JE, Cannon CP. Acute myocardial infarction. Lancet. 2017;389(10065):197-210.
Thygesen K, Mair J, Giannitsis E, et al. How to use high-sensitivity cardiac troponins in acute cardiac care. Eur Heart J. 2012;33(18):2252-2257.
Rodseth RN, Biccard BM, Le Manach Y, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery. J Am Coll Cardiol. 2014;63(2):170-180.
Duceppe E, Parlow J, MacDonald P, et al. Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery. Can J Cardiol. 2017;33(1):17-32.
Porter TR, Shillcutt SK, Adams MS, et al. Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults. J Am Soc Echocardiogr. 2015;28(1):40-56.
Katritsis DG, Gersh BJ, Camm AJ. Clinical Cardiology: Current Practice Guidelines. 3rd ed. Oxford University Press; 2024.
Lee TH, Marcantonio ER, Mangione CM, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043-1049.
Ford MK, Beattie WS, Wijeysundera DN. Systematic review: prediction of perioperative cardiac complications and mortality by the revised cardiac risk index. Ann Intern Med. 2010;152(1):26-35.
Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845-850.
Bilimoria KY, Liu Y, Paruch JL, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator. J Am Coll Surg. 2013;217(5):833-842.e1-3.
Fleischmann KE, Beckman JA, Buller CE, et al. 2024 ACC/AHA Guideline for the Management of Patients Undergoing Noncardiac Surgery. J Am Coll Cardiol. 2024.
Wijeysundera DN, Pearse RM, Shulman MA, et al. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet. 2018;391(10140):2631-2640.
Halvorsen S, Mehilli J, Cassese S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J. 2022;43(39):3826-3924.
Walsh M, Devereaux PJ, Garg AX, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery. Anesthesiology. 2013;119(3):507-515.
Youn YJ, Lee J, Park JJ, et al. Postoperative statin treatment may be associated with improved mortality in patients with myocardial injury after noncardiac surgery. Sci Rep. 2020;10(1):11616.
POISE Study Group, Devereaux PJ, Yang H, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet. 2008;371(9627):1839-1847.
Oscarsson A, Gupta A, Fredrikson M, et al. To continue or discontinue aspirin in the perioperative period: a randomized, controlled clinical trial. Br J Anaesth. 2010;104(3):305-312.
Park J, Oh AR, Kwon JH, et al. Association Between Antiplatelet Therapy and Long-Term Mortality in Patients With Myocardial Injury After Noncardiac Surgery. Heart. 2023;109(16):1229-1236.
Devereaux PJ, Duceppe E, Guyatt G, et al. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet. 2018;391(10137):2325-2334.
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. J Am Coll Cardiol. 2014;64(24):e139-e228.
Levy M, Heels-Ansdell D, Hiralal R, et al. Prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurement after noncardiac surgery. Anesthesiology. 2011;114(4):796-806.
Mauermann E, Puelacher C, Lurati Buse G. Myocardial injury after noncardiac surgery: an underappreciated problem and current challenges. Curr Opin Anaesthesiol. 2016;29(3):403-412.
Ackland GL, Abbott TEF, Minto G, et al. Heart rate recovery and morbidity after noncardiac surgery. PLoS One. 2019;14(8):e0221277.
Derechos de autor 2026 Gustavo Andres Diaz Cruz , María Paula Gómez Silvestre, Julián Mateo Gelvez Díaz , David Mauricio Lizarazo Castillo ; Brayan Franchesco Nocua Martínez ; Maria Catalina Vargas Quintero, Ingrid Tatiana Castillo Molina, María José Osorio , Anna María Oviedo Prada , Andrés Leandro Ladino Güezguán
Esta obra está bajo licencia internacional Creative Commons Reconocimiento 4.0.
.png)
.png)
1.png)
