Perioperative Infarcts: Epidemiology, predictors and post-op monitoring

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1 Friday Nov 3rd, pm Perioperative Infarcts: Epidemiology, predictors and post-op monitoring Dr Carol Chong Geriatrician Northern Health, Epping, Victoria, Australia

2 How I became interested in this Orthopaedic Intern, 1 st job Aged Care registrar Orthopaedic-geriatric unit Incidence of asymptomatic Troponin elevations after orthopaedic surgery RCT intervention M.D field back

3 Epidemiology How common are peri-op infarcts? Cardiac complications (MI, Heart Failure, VT) up to 5% of patients Devereaux et al CMAJ 2005 Lowe et al Med J Aust 2006 Mortality after MI in hospital 25-65% at 1 year Lowe et al Med J Aust 2006 back

4 How do we define an AMI after non-cardiac surgery? Third Universal definition of Myocardial Infarction Redefined in 2007, updated in 2012 Emphasised rise and fall of cardiac markers with level above 99 th percentile of upper reference range Together with symptoms of ischaemia or ECG changes Thygesen et al 2007 J Am Coll Cardiol Thygesen et al 2012 Circulation back

5 Universal Classification of MI Type I: Spontaneous MI Type II: MI secondary to an ischaemic imbalance Type III: MI resulting in death when biomarker values are unavailable Type IVa: MI related to PCI Type IVb: MI related to stent thrombosis Type V: MI related to CABG Thygesen et al 2012 Circulation back

6 2 proposed mechanisms Type 1 peri-op MI traditional for pts with non-surgically related MI. Arterial thrombosis of coronary artery by plaque fissuring or acute luminal thrombosis in areas of stenosis Dawood et al, landmark study Autopsy study fatal post-op MI 42 pts -significant atherosclerotic obstruction in >50% -Site of infarct not necessarily site of most severe stenosis Dawood et al Int J Cardiol back 1996

7 Type II peri-op MI Demand ischaemia hemodynamic changes may relate to troponin abnormalities Angiography post- MI presence of chronic severe coronary artery disease without thrombus or ulcerated plaques Imbalance between myocardial oxygen supply and demand Modesti et al Intern Emerg Med 2006 McFalls et al Eur Hear J 2008 back

8 Peri-operative Myocardial Infarction Mostly silent eg. delirium, analgesics blunt pain sensation Either end of surgery or hours later ECG changes non-q wave Sun et al Am Heart J 2007 Badner et al Anesthesiology 1998 back

9 Pathophysiology of peri-op MI Complex! Surgery sympathetic system Inflammation Hypoxia Increased pro inflammatory cytokines Platelet activation Hypercoagulable environment Oxygen demand Increases back

10 The Cardiac Myocyte and Troponins back

11 Troponin I Exists in 2 forms within myocardium 1. Cytosolic component 3% Troponin I 2. Structural (myofibrillar) form Unbound cytosolic component released acutely Concept of reversible ischaemia In practice, difficult to distinguish clincally back

12 Incidence of post-op troponin Orthopaedic series elevations Incidence between % Studied mainly in the vascular population Incidence 8-33% Jules-Elysse et al J Clin Anesth 2001 Mouzopoulos et al J Trauma 2007 Ausset et al Arch Orthop Trauma Surg 2008 Dawson-Bowling et al Injury 2008 Chong et al Age Ageing 2009 Kim et al Circulation 2002 Landesberg et al J Am Coll Cardiol 2005 Oscarsson et al Acta Anaesthesia Scand 2004 Barbagallo et al J Clin Anesthesia 2006 back

13 Troponin Issues Incidence likely related to sensitivity of biomarker Biomarker of myocardial injury Non specific marker of illness Determining cause of troponin elevation helps to guide management For pts with a high pretest probability of ACS due to a thrombotic event, diagnostic value of troponin is useful Difficulty lies in troponin as a screening tool if patients with a low pre-test probability are tested back

14 Concept of Myocardial Infarction and Myocardial Injury after Noncardiac Surgery (MINS) Broader term than MI. Results in myocardial injury during (+/-necrosis) or within the first 30 days after non-cardiac surgery Prognostically relevant MI and MINS Due to an ischaemic etiology May not have the typical features eg. symptoms, ECG Botto et al Anaesthesiology back 2014

15 MINS incidence VISION study (Vascular Events in Noncardiac Surgical Patient Cohort Evaluation Study) Trop measured 6-12 hours after surgery and days 1,2,3 post op. 15,065 pts Trop >0.03ng/ml 11.6% post-op troponin elevation 8% MINS Botto et al Anaesthesiology back 2014

16 MINS incidence 8% (VISION) 41.8% fulfilled the universal definition of MI Only 15% with MINS had an ischaemic symptom 30 day mortality (115 pts) was 9.8% in MINS pts and 1.1% without. Vascular cause of death in 62 (53.9%) 10 fold mortality with Troponin >0.30 Botto et al Anaesthesiology back 2014

17 Prognosis MI and MINS worse short and long term outcomes In hospital mortality after peri-op MI 5-25% Devereaux et alcmaj 2005 Badner Anesthesiology 1998 back

18 Levy et al Anesthesiology 2011

19

20 Predictors 1977 Goldman et al created a risk evaluation system (NEJM) 1999 Lee et al Revised Goldman Cardiac Risk Index back

21 back

22 Revised Goldman Cardiac Risk Index back

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24

25 Other predictors American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Calculator back

26 back

27 back

28 Post-op monitoring Is screening indicated to detecting cardiac injury peri-operatively? back

29 Post-op monitoring Is screening indicated to detecting cardiac injury peri-operatively? Perhaps for high risk surgery Using Troponin and ECGs Recommendations 2014 ACC/AHA guidelines usefulness uncertain 2014 European Society of Cardiology may be considered 3rd Universal definition of MI before and 48-72hrs after in high risk pt s

30 Screening Issues 1. Will the test change the care of my patient eg. Asymptomatic pt with Normal ECG and mild troponin elevation 2. What are the probability and potential adverse consequences of a false positive result eg. Anticoagulating, bleeding risk, PCI risk 3. Is the pt in danger in the short term if I do not perform the test? Beckman Circulation 2013 back

31

32 Troponin I Incidence of a troponin elevation post-operatively was 70/187 (37.4%) randomised. 12 patients had a post-op AMI (6.4%) SC: 5 patients 41.7% dead at 6 months CC: 7 patients 42.8% dead at 6 months 1 year mortality No difference between randomised groups 6/35 (17.1%) dead in each group (p=1.000) Troponin was a prognostic marker back

33 Preventative strategies B blockers POISE Aspirin and clonidine - POISE II Ivabradine and atorvastatin Dabigatran (a Direct Thrombin Inhibitor) and Omeprazole (a Proton-pump Inhibitor) in Patients Suffering Myocardial Injury after Noncardiac Surgery (ongoing Oct 2017) Devereaux back

34 back

35 POISE Trial results-8351 pts at risk of atherosclerotic disease Fewer in bblocker group 244 (5.8%) versus placebo 290 (6.9%) reached primary endpont (composite CV death, non fatal MI and nonfatal cardiac arrest) MI 5% at 30 days (4.2% bblocker vs 5.7% placebo) More death in bblocker group 29 (3.1%) vs 97 (2.3%) Hr 1.33, , p=0.0317) More stroke 41 (1%) vs 19 (0.5%) HR 2.17, , p=0.0053). Clinically significant hypotension and stroke explains increased risk of death back

36 back

37 back

38 back

39 Screening/Monitoring more research needed Few prospective RCTs in this field Newer cardiac Ix Coronary calcium scores, Cardiac MRI Use of peri-op beta blockers controversial eg. Duration of initiation prior to surgery, dose and titration Value of testing biomarkers peri-op needs more Ix. back

40 Summary Post-op AMI assoc with worse outcomes Troponin elevations confer a worse prognosis However, there are no validated treatments for asymptomatic troponin elevations post-op as yet thus screening is not recommended

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