The post-operative electrocardiogram and creatine kinase: Implications for diagnosis of myocardial infarction after non-cardiac surgery

  • Mary E. Charlson
    Correspondence
    Author to whom correspondence should be addressed
    Footnotes
    Affiliations
    Clinical Epidemiology Unit, The Department of Medicine and The Department of Surgery, Cornell University Medical College, New York, NY 10021, U.S.A.
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  • C. Ronald Mackenzie
    Affiliations
    Clinical Epidemiology Unit, The Department of Medicine and The Department of Surgery, Cornell University Medical College, New York, NY 10021, U.S.A.
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  • Kathy L. Ales
    Footnotes
    Affiliations
    Clinical Epidemiology Unit, The Department of Medicine and The Department of Surgery, Cornell University Medical College, New York, NY 10021, U.S.A.
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  • Jeffrey P. Gold
    Affiliations
    Clinical Epidemiology Unit, The Department of Medicine and The Department of Surgery, Cornell University Medical College, New York, NY 10021, U.S.A.
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  • Gordon F. Fairclough Jr.
    Affiliations
    Clinical Epidemiology Unit, The Department of Medicine and The Department of Surgery, Cornell University Medical College, New York, NY 10021, U.S.A.
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  • G. Thomas Shires
    Affiliations
    Clinical Epidemiology Unit, The Department of Medicine and The Department of Surgery, Cornell University Medical College, New York, NY 10021, U.S.A.
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  • Author Footnotes
    ∗ Dr Charlson is a Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine.
    † Dr Ales is a George Morris Piersol American College of Physicians Research and Teaching Scholar.
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      Abstract

      The objective of this study was to evaluate different approaches to the diagnosis of post-operative myocardial infarction. A total of 232 patients, mostly hypertensive and/or diabetic patients, who were undergoing elective non-cardiac surgery were evaluated pre-operatively. They were followed serially from the day of operation to discharge or the sixth post-operative day with daily clinical evaluations, electrocardiograms, creatine kinase and creatine kinase isoenzymes.
      In total 22% (51/232) of the patients had post-operative ECG changes in two or more leads. Only 1 % developed new Q waves; most of the changes involved changes in the T or ST segments. Seventy percent of patients who had changes in their electrocardiogram were completely asymptomatic. The highest risk of ECG changes or symptoms occurred on the day of operation and the first postoperative day; evidence of post-operative infarction was infrequent after the second post-operative day. Creatine kinase levels rose an average of 250–300 IU on the first and second post-operative day (also the peak time for post-operative ECG changes), reducing its utility as an adjunct to the diagnosis of post-operative infarctions. Importantly, 52% (12/23) of the patients who had ⩾ 5% MB isoenzyme had neither ECG changes nor symptoms; the diagnosis of a myocardial infarction should not be made in these patients.
      In summary, most patients who experience ischemia or infarction post-operatively are asymptomatic. Symptoms should not be required for the diagnosis of post-operative infarction. Seemingly minor differences in criteria can produce major discrepancies in post-operative myocardial infarction rates (from 1 to 9%). The development of a final set of criteria will require further study but the diagnosis of post-operative infarction should probably be based on ECG changes, their duration and consistency, and the association of a positive MB fraction.

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      References

        • Goldman L.
        • Caldera D.L.
        • Nussbaum S.R.
        • et al.
        Multifactorial index of cardiac risk in noncardiac surgical procedures.
        N Eng J Med. 1977; 297: 845-850
        • Von Knorring J.
        Post-operative myocardial infarction: a prospective study in a risk group of surgical patients.
        Surg. 1981; 90: 55-60
        • Wroblewski F.
        • LaDue J.S.
        Myocardial infarction as a postoperative complication of major surgery.
        JAMA. 1952; 150: 1212-1216
        • Wasserman F.
        • Bellet S.
        • Saichek R.P.
        Post-operative myocardial infarction.
        N Eng J Med. 1955; 252: 967-973
        • Driscoll A.C.
        • Hobika J.H.
        • Etsten B.E.
        • et al.
        Clinically unrecognized myocardial infarction following surgery.
        N Eng J Med. 1961; 264: 633-639
        • Zeldin R.A.
        Assessing cardiac risk in patients who undergo noncardiac surgical procedures.
        Can J Surg. 1984; 27: 402-404
        • Jeffrey C.C.
        • Kunsman J.
        • Cullen D.J.
        • et al.
        A prospective evaluation of the cardiac risk index.
        Anesth. 1983; 58: 464-464
        • Gerson M.C.
        • Hurst J.M.
        • Hertzberg V.S.
        • et al.
        Cardiac prognosis in noncardiac surgery.
        Ann Int Med. 1985; 103: 832-837
        • Detsky A.S.
        • Abrams H.B.
        • McLaughlin J.R.
        • et al.
        Predicting cardiac complications in patients undergoing non-cardiac surgery.
        J Gen Int Med. 1986; 1: 211-219
        • Rose G.A.
        • Blackburn H.
        Cardiovascular Survey Methods.
        in: World Health Organization Monograph, Belgium1968: 172-177
        • Goldman L.
        • Hashimoto B.
        • Cook E.F.
        • et al.
        Comparative reproducibilities and validities of systems for the assessment of cardiovascular functional class.
        Circ. 1981; 64: 1227-1234
        • Romhilt D.W.
        • Estes E.H.
        A point score system for the ECG diagnosis of left ventricular hypertrophy.
        Am Heart J. 1968; 75: 752-758
        • Rosalki S.B.
        An improved procedure for serum creatine phosphokinase determination.
        J Lab Ctin Med. 1967; 60: 696-705
        • Farrington C.
        • Chalmers A.H.
        The effect of dilution on creatine kinase activity.
        Clin Chim Acta. 1976; 73: 217-219
        • Righetti A.
        • Crawford M.H.
        • Rourke R.A.
        • et al.
        Detection of perioperative myocardial damage after coronary artery bypass graft surgery.
        Circ. 1977; 55: 173-178
        • Mercer D.W.
        Separation of tissue and serum creatine kinase isoenzymes by ion exchange column chromatography.
        Clin Chem. 1974; 120: 36-40
        • Roberts R.
        • Henry P.D.
        • Witteeveen S.A.
        • et al.
        Quantification of serum kinase activity.
        Am J Cardiol. 1974; 33: 650-654
        • Lee T.H.
        • Weisberg M.C.
        • Cook E.F.
        • et al.
        Evaluation of creatine kinase and creatine kinase-MB for diagnosing myocardial infarction clinical impact in the emergency room.
        Arch Int Med. 1987; 147: 115-121
        • Cutler S.J.
        • Ederer F.
        Maximum utilization of the life table method in analyzing survival.
        J Chron Dis. 1958; 8: 699-712
      1. SAS User's Guide Statistics. SAS Institute; N.C, Cary1985: 433-507 (Version 5 Edition)
        • Rao T.L.K.
        • Jacobs K.H.
        • El-Etr A.A.
        Reinfarction following anesthesia in patients with myocardial infarction.
        Anest. 1983; 59: 499-505
        • Dack S.
        Symposium on cardiovascular-pulmonary problems before and after surgery. II. Post-operative problems: post-operative myocardial infarction. Am J Card. 12. 1963: 423-430
        • Chamberlain D.A.
        • Edmonds-Seal J.
        Effects of surgery under general anesthesia on the electrocardiogram in ischemic heart disease and hypertension.
        Brit Med J. 1964; 2: 784-787
        • Rosen M.
        • Mushin W.W.
        • Kilpatrick G.S.
        • et al.
        Study of myocardial ischemia in surgical patients.
        Brit Med J. 1966; 2: 1415-1420
        • Mauney F.M.
        • Ebert P.A.
        • Sabiston D.C.
        Postoperative myocardial infarction: a study of predisposing factors, diagnosis and mortality in a high risk group of surgical patients.
        Ann Surg. 1970; 172: 497-503
        • Lee T.H.
        • Goldman L.
        Serum enzyme assays in the diagnosis of acute myocardial infarction: recommendations based on a quantitative analysis.
        Ann Int Med. 1986; 105: 221-233
        • Savignano T.
        • Hanok A.
        • Juo J.
        Creatine phosphokinase activity.
        Am J Clin Path. 1969; 51: 76-85
        • Roberts R.
        • Godwa K.
        • Ludbrook P.A.
        • et al.
        Specificity of elevated serum MB creatine phosphokinase activity in the diagnosis of acute myocardial infarction.
        Am J Card. 1975; 36: 433-437
        • Sortie D.
        • Huseby N.E.
        • Kluge T.
        Ischemia during arterial reconstructive surgery.
        Scan J Thor Cardiovasc Surg. 1977; 11: 151-158
        • Dison S.H.
        • Fuchs J.A.
        • Ebert P.A.
        Changes in serum creatine phosphokinse activity following thoracic cardiac and abdominal operations.
        Arch Surg. 1971; 103: 66-68
        • Strom S.
        • Bendz R.
        • Olin C.
        • et al.
        Serum enzymes with special reference to CK-MB following coronary bypass surgery.
        Scand J Thor Cardiovasc Surg. 1979; 13: 53-59
        • Strom S.
        • Mogensen L.
        • Bendz R.
        Serum CK-MB kinetics in acute myocardial infarction and after coronary bypass operations.
        Scand J Cardiovase Surg. 1979; 13: 61-66
        • Dixon S.H.
        • Limbird L.E.
        • Roe C.R.
        • et al.
        Recognition of postoperative acute myocardial infarction.
        Circ. 1973; 48: 137-140
        • Bendz R.
        • Strom S.
        Diagnostic significance of serum CK-MB elevations following surgical damage to skeletal muscles.
        Scan J Thor Cardiovasc Surg. 1981; 15: 199-204
        • Taung S.H.
        Circulating CK-MB and CK-BB isoenzymes after gastrointestinal surgery.
        J Clin Pathol. 1982; 35: 200-203
        • Balderman S.C.
        • Bhayana J.N.
        • Stenbach J.J.
        • et al.
        Perioperative myocardial infarction: a diagnostic dilemma.
        Ann Thor Surg. 1980; 30: 370-377
        • Val P.G.
        • Pelletier L.C.
        • Hernandez M.G.
        • et al.
        Diagnostic criteria and prognosis of perioperative myocardial infarction following coronary bypass.
        J Thor Cardiovasc Surg. 1983; 86: 878-886
        • Goldman L.
        Cardiac risks and complications of noncardiac surgery.
        Ann Int Med. 1983; 98: 504-513
        • Graeber G.M.
        Creatine kinase: its use in the evaluation of perioperative myocardial infarction.
        Surg Clin N Amer. 1985; 655: 539-551
        • Wicks R.
        • Usategui-Gomez M.
        • Miller M.
        • et al.
        Immunochemical determinations of CK-MB isoenzymes in human serum. II. An enzymatic approach.
        Clin Chem. 1982; 28: 54-58
        • Steen P.A.
        • Tinker J.H.
        • Tarhan S.
        Myocardial reinfarction after anesthesia and surgery.
        JAMA. 1978; 239: 2566-2570
        • Goldman L.
        • Caldera D.L.
        • Southwick F.S.
        • et al.
        Cardiac risk factors and complications in non-cardiac surgery.
        Medicine. 1978; 57: 357-369
        • Skinner J.F.
        • Pearce M.L.
        Surgical risk in the cardiac patients.
        J Chron Dis. 1964; 17: 57-72
        • Topkins M.J.
        • Artusio J.F.
        Myocardial infarction and surgery: a five year study.
        Anesth Analg. 1964; 43: 716-720