p.72 抽出テキスト

P2Y12 inhibitor. The median peak measured hs-cTn concentration associated with the diagnosis of MINS was 82 ng/L. More than 90% of MINS events occurred without a clinical symptom or sign of cardiac ischaemia. Dabigatran/placebo was initiated a median of 6 days after the operation and the average time on study drug was ≏9 months. Among patients with MINS randomly assigned to receive dabigatran (n = 877) or placebo (n = 877), the composite primary efficacy outcome of a major vascular complication—including vascular mortality, MI, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic VTE—occurred in fewer patients randomized to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs. 133 [15%] of 877 patients assigned to placebo; HR, 0.72; 95% CI, 0.55–0.93; P = 0.0115). There was no increase in major bleeding. Based on these data, in patients with MINS and at low risk of bleeding, initiation of dabigatran 110 mg orally b.i.d. may be considered about 1 week after NCS.

8.2 Spontaneous myocardial infarction

(after day 2) The incidence of post-operative spontaneous MI after day 2 seems to be about 0.5% within 30 days, and 1–2% within 365 days for patients undergoing major NCS with established CAD, PAD, or aged .65 years.8 In the immediate post-operative period (,5 days), bleeding is a major concern and limits the use of antiplatelet and anticoagulant therapy, depending on the site and extent of surgery. Otherwise, the same principles as for MI therapy should generally be applied following the recommendations of speciality guidelines.98,171

8.3 Takotsubo syndrome

The incidence of peri-operative Takotsubo syndrome remains unknown, as none of the studies with PMI screening used echocardiography in all patients during PMI work-up. Increased awareness in the non-operative setting has led to a substantial increase in the detection of Takotsubo syndrome, and the use of TTE in the work-up of PMI is strongly encouraged. Anecdotal evidence suggests that it is likely that the incidence is also higher than expected in the perioperative setting.8,41,101,109–111,118,413,564,636–639,641,644

8.4 Acute heart failure

The incidence of post-operative acute HF seems to be 1–2% within 30 days and 4–6% within 365 days in patients with established CAD, PAD, or aged .65 years undergoing major NCS.8 Pre-existing diagnosed or undiagnosed chronic HF and volume loading in the perioperative and post-operative periods are important contributors. In the absence of studies specifically investigating acute HF postoperatively, the general principles of acute HF diagnostic work-up and therapy should be applied.651

8.5 Venous thromboembolism

The incidence of VTE in the peri-operative phase is currently unknown and likely underreported due to the lack of systematic screening methods and the limited validity of diagnostic tools (e.g. D-dimer, typical pain symptoms) in this setting. It is associated with high peri-operative mortality (≏17%).322 Risk factors for postoperative VTE/PE include type of surgery (e.g. high-risk hip arthroplasty, open prostatectomy, open surgery for malignancy), acute renal insufficiency, MI, and post-operative infection.322

Stratification of the extent of embolism (e.g. massive, submassive, and subsegmental; high risk, intermediate high/low risk, and low risk) is important to predict mortality and guide therapeutic strategy.652 Pulmonary embolism should be suspected in patients with PMI without a clear cause. Close haemodynamic monitoring and monitoring of RV function (echocardiography, CT) is essential to determine which PE patients require aggressive therapy. There is currently a lack of evidence regarding adequate antithrombotic therapy in patients with post-operative PE, since recent major surgery or trauma was a contraindication in previous trials of thrombolytic or anticoagulant therapy.653 Small case series support the use of systemic thrombolysis, surgical thrombectomy,654 or catheter-directed therapies in massive PE. In general, anticoagulation, preferably LMWH or fondaparinux, should be initiated as early as possible.652 Oral anticoalgulant therapy, preferably NOAC due to the lower bleeding risk, should be initiated, depending on post-operative renal function and bleeding risk, as early as possible for at least 3 months.652 Rescue thrombolytic therapy is recommended for patients with PE and haemodynamic deterioration on anticoagulation treatment in the post-operative phase, if possible, according to bleeding risk.652 As an alternative to thrombolytic therapy for massive PE, surgical embolectomy or percutaneous catheter-directed treatment should be considered for patients with haemodynamic deterioration on anticoagulation treatment, particularly in patients with high bleeding risk.

8.6 Atrial fibrillation and other relevant

arrhythmias Post-operative AF is defined as new-onset AF in the immediate postoperative period; its incidence ranges between 2–30%, with peak incidence 2–4 days post-operatively.655,656 Although many post-operative AF episodes are self–terminating and some are asymptomatic, post-operative AF has been associated with a four- to five-fold risk of AF recurrence in the 5 years following cardiac surgery, while the risk of recurrence after NCS is less well described.656–660 Importantly, post-operative AF is a risk factor for stroke, MI, and death compared with non-post-operative AF patients.656,658,661 Post-operative AF may also lead to haemodynamic instability, prolonged hospital stay, infections, renal complications, bleeding, increased in-hospital death, and greater healthcare costs.662–664 The essential principles of the prevention and management of post-operative AF are outlined in Figure 20.

8.6.1 Prevention of post-operative atrial

fibrillation Pre-operative use of beta-blockers is associated with reduced incidence of post-operative AF,204,665–667 but not major adverse events such as death, stroke, or AKI.668 Importantly, in a large RCT, peri-operative metoprolol was associated with increased mortality risk.185 In a meta-analysis, amiodarone (oral or i.v.) was equally effective in reducing post-operative AF as betablockers,207 whereas their combination was better than betablockers alone.208 Lower cumulative doses of amiodarone (,3000 mg) may be effective, with fewer adverse events.669–671

ESC Guidelines                                                                                                                                                                                     3897

Downloaded from academic.oup.com/eurheartj/article/43/39/3826/6675076 by guest on 07 October 2026