From the Guidelines
Patients undergoing gastrectomy are at a significant risk for acute coronary syndrome (ACS) due to the surgical stress and potential underlying cardiovascular disease, emphasizing the need for thorough preoperative cardiovascular evaluation and management. The risk of ACS in these patients is a critical concern, as it can lead to significant morbidity and mortality. According to the 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery 1, obesity, which is often associated with gastrectomy, is a growing global epidemic and affects more than one-third of the US adult population.
Key factors to consider in assessing the risk of ACS in patients requiring gastrectomy include:
- Obesity and its related diseases, such as type 2 diabetes, hypertension, and dyslipidemia
- History of cardiovascular disease (CVD), including prior cardiac history, which has been associated with greater risks of perioperative cardiac arrest and 30-day mortality 1
- The type of gastrectomy procedure, with sleeve gastrectomy potentially having fewer adverse events than Roux-en-Y gastric bypass 1
Preoperative assessment and management should focus on identifying and mitigating these risk factors to reduce the likelihood of ACS, including careful attention to history and risk factors during preoperative assessments, and consideration of the discontinuation of certain medications such as GLP-1 receptor agonists before noncardiac surgery 1. The goal is to optimize the patient's cardiovascular status before surgery to minimize the risk of ACS and ensure the best possible outcomes in terms of morbidity, mortality, and quality of life.
From the Research
Risk Factors for Acute Coronary Syndrome (ACS)
- Age: being at least 65 years of age is a common risk factor for ACS 2
- Smoking: current smokers are at increased risk of developing ACS 2
- Hypertension: high blood pressure is a risk factor for ACS 2
- Diabetes mellitus: patients with diabetes are at increased risk of developing ACS 2
- Hyperlipidemia: high levels of lipids in the blood is a risk factor for ACS 2
- Family history of premature coronary artery disease: a family history of coronary artery disease increases the risk of ACS 2
Symptoms of ACS
- Chest discomfort that is substernal or spreading to the arms or jaw is a symptom predictive of ACS 2
- Chest pain that can be reproduced with palpation or varies with breathing or position is less likely to signify ACS 2
- Having a prior abnormal cardiac stress test result indicates increased risk of ACS 2
Diagnosis of ACS
- Electrocardiography (ECG) should be performed immediately (within 10 minutes of presentation) to distinguish between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS) 3, 4
- High-sensitivity troponin measurements are the preferred test to evaluate for non-ST-segment elevation myocardial infarction (NSTEMI) 3
- Risk stratification should be calculated using Thrombosis in Myocardial Infarction (TIMI) or HEART (History, ECG, Age, Risk factors, initial Troponin) score 4
Relationship between Gastrectomy and ACS
- There is no direct evidence in the provided studies to suggest a relationship between gastrectomy and the risk of ACS 3, 4, 2, 5, 6
- However, patients undergoing gastrectomy may have underlying health conditions that increase their risk of developing ACS, such as hypertension, diabetes, and hyperlipidemia 2, 5
Management of ACS
- Patients with ACS should receive coronary angiography with percutaneous or surgical revascularization 2
- Other important management considerations include initiation of dual antiplatelet therapy and parenteral anticoagulation, statin therapy, beta-blocker therapy, and sodium-glucose cotransporter-2 inhibitor therapy 2