Magnitude of the Problem

Worldwide, over 200 million adults undergo major noncardiac surgery annually,^{5, 6} and more than 10 million of these patients will suffer MINS during the first 30 days after surgery.⁵  Myocardial injury is the most common major vascular complication after noncardiac surgery.  We recently completed a large (8351 patients) multicenter international (190 centres in 23 countries) perioperative prophylactic RCT that compared the impact of a beta-blocker versus placebo (i.e., the POISE Trial).⁷  In the placebo group of the POISE Trial 1.4% of patients suffered a vascular death, 0.5% suffered a stroke, 0.5% suffered a nonfatal cardiac arrest, and 5.7% suffered a myocardial injury in the first 30 days.⁷  Despite the magnitude of this problem, there is not a single established effective and safe intervention to improve the outcome of patients suffering MINS.  The striking absence of effective interventions reflects the lack of large RCTs evaluating potential interventions.  MINS is therefore a major neglected public health problem.

Why we should find a treatment for MINS

Myocardial injury after noncardiac surgery (MINS) differs from non-operative myocardial infarction in two ways; it has a poorer prognosis (patients suffering MINS are 2 times more likely to die within 30 days compared to non-operative myocardial infarction in the emergency room) and paradoxically its treatment is less intensive.^{1, 8-10}  This difference in the intensity of treatment is likely influenced by several factors including: (1) a majority of patients suffering MINS do not experience ischemic symptoms^{,1, 11} potentially influencing physicians’ perception of the severity of the event; (2) there is debate as to the pathophysiology of MINS ¹² (although emerging evidence does suggest that coronary arterial thrombosis is an important mechanism of MINS);5 and (3) no randomized controlled trial (RCT) has evaluated an intervention to manage MINS, and hence physicians are uncertain about the risk-benefit ratio of potential interventions (e.g., interventions that are effective in the management of  non-operative myocardial infarction).⁵  From a human and economic perspective, it is a tragedy that some patients undergoing noncardiac surgery for important reasons (e.g., to obtain a cure of their cancer or to become mobile after a new prosthetic joint) fail to obtain these benefits, because they suffer MINS that ultimately takes their life.  There is an urgent need for clinical trials to identify effective therapies to improve the outcomes of patients suffering MINS.