Major adverse cardiovascular events (MACE)

Major adverse cardiovascular events (MACE), is a composite endpoint frequently used in cardiovascular disease assessment.



Classically 3-point MACE is defined as a composite of nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death.



Others define MACE as CVD events: hospitalization  for heart failure, ischemic cardiovascular events, cardiac death, myocardial infarction.



The incidence of perioperative myocardial infarction is about 0.9%. 



There is a larger percentage of patients experience a perioperative increase in cardiac troponins without other criteria for myocardial infarction.



Factors associated with an increased risk of MACE are patient specific: advanced age, high American Society of Anesthesiologists (ASA) class, kidney disease, anemia and surgery specific; type of procedure, urgency, complexity, intraoperative complications.



The Thrombolysis in Myocardial Infarction and Global Registry of Acute Cardiac Events scoring system  allows prediction of 30-day, 6-month, and 12-month mortality rates in patients with ST-segment elevation MI (STEMI) and non–ST segment elevation MI (NSTEMI), respectively. 



NSTEMI is the most common type of perioperative myocardial infarction.



NSTEMI is often caused by an impaired balance between myocardial oxygen supply and demand in the absence of complete occlusion of a coronary vessel. 



The need for urgent revascularization is less stringent compared with STEMI, but prevention or prompt treatment of anemia, hypotension, hypoxia, pain, and tachycardia is of primary importance.



PCI is considered in patients with perioperative STEMI, especially in patients with good life expectancy and moderate to large infarctions. 



Only  patients at low risk of death and at high risk of bleeding should be treated with medical therapy alone.



Aspirin and low-dose oral β-blockers should be initiated within 24 hours in all patients with Mi nonSTEMI  unless contraindicated. 



A platelet receptor P2Y12 inhibitor may be added when bleeding risk is decreased sufficiently (clopidogrel, prasugrel, ticagrelor).



Angiotensin-converting enzyme inhibitors should be started in patients with an ejection fraction of less than 40%, hypertension, or diabetes, including those with stable chronic kidney disease.



The use of Intraaortic balloon pump, volatile anesthetic agents, leukocyte-depleted red blood cell transfusions, protective ventilation, and vacuum-assisted closure therapy reduce mortality rates in in cardiac and other surgical procedures. 



To reduce mortality and prevent MACE in patients with chronic stable CAD: β-blockers are a mainstay of therapy in chronic stable CAD.



However, little evidence exists that β-blockers  prolonged use of results in improved survival or lower MACE rate.



In a study of over 20,000 patients that were and were not treated with β-blockers, demonstrated no statistically significant difference in the rates of MACE between patients with established CAD and no prior MI during a median follow up of nearly 4 years.



Furthermore, among patients with previous history of MI, the outcomes were numerically favorable in patients with versus without β-blocker use, but this difference was not statistically significant. 



Studies suggest a modest benefit  with β-blocker s in patients with a recent MI, but not in those without prior acute MI.



Guidelines for chronic stable CAD management for the use of β-blockers in patients with prior MI or history of heart failure, but not in other patients with chronic stable CAD.



Calcium-channel blockers, nitrates, and ranolazine, have not been shown to have an effect on survival or MACE events. 



Neither nifedipine nor amlodipine reduce  the rates of cardiovascular death or MI in chronic stable angina.



In the Non−ST-Elevation Acute Coronary Syndromes (



The MERLIN-TIMI36 trial, the NSTEMI coronary syndromes  that were stabilized , ranolazine did not significantly reduce the primary endpoint of cardiovascular death, MI, or recurrent ischemia compared with placebo.



No cardiovascular trials have ever been performed with nitrates in this patient population.



Antiplatelet therapy improves outcomes in patients with established CAD.



The Antithrombotic Trialists’ Collaboration meta-analysis of over 135,000 patients, with prior vascular events, previous coronary revascularization procedures and/or stable angina, demonstrated a significant reduction in MACE with antiplatelet therapy, primarily aspirin.



There is no difference in efficacy or safety between low-dose (75 to 150 mg daily) and higher-dose aspirin. 



The use of thienopyridines, such as clopidogrel, instead of aspirin may provide an additional modest benefit,  but is not recommended unless patients are unable to tolerate aspirin. 



The use of dual antiplatelet therapy in patients with chronic stable CAD is more controversial.



Lowering of low-density lipoprotein cholesterol (LDL-C) with statin therapy is a mainstay of chronic stable CAD management. 



Numerous trials and multiple meta-analyses have demonstrated the benefits of LDL-C lowering with with statins on cardiovascular outcomes. 



A consistent benefit of intensive statin therapy is observed in patients with established CAD: reductions in cardiovascular and all-cause mortality, and MI.



High-intensity statin treatment for all eligible patients with established CAD.



For patients requiring additional LDL lowering despite maximally tolerated statin therapy: ezetimibe has been shown to provide additional, modest clinical benefit in combination with a statin.



Therapies aimed at raising high-density lipoprotein (HDL) and/or lowering triglycerides have failed to provide additional clinical benefits.



In patients with stable CAD, angiotensin-converting enzyme inhibitor (ACE-I), angiotensin receptor blocker (ARB), and mineralocorticoid receptor antagonists have not been consistently demonstrated to improve outcomes above and beyond blood pressure lowering.



These agents reduce total mortality, MI, stroke, and heart failure in several key subgroups of patients, such as those after acute MI with reduced left ventricular ejection fraction (LVEF), symptomatic heart failure, and high-risk diabetes, and may also improve renal outcomes in patients with chronic kidney disease (CKD), particularly with diabetic nephropathy.


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