DECLARATION OF CONFLICT OF INTEREST. None declared

Transcription

1 DECLARATION OF CONFLICT OF INTEREST None declared

2 Coronary Artery Disease, Aspirin, and Perioperative Myocardial Infarction and Bleeding in Orthopedic Surgery Brandon Oberweis, MD*, Swetha Nukala, MBBS*, Andrew Rosenberg, MD**, Steven Stuchin, MD, Martha Radford, MD*, Jeffrey Berger, MD* NYU Langone Medical Center *Department of Medicine Department of Surgery **Department of Anesthesiology

3 Background Increasing number of orthopedic surgical procedures are being performed Little data in the literature on combined perioperative thrombotic AND bleeding events Majority of studies investigating thrombotic events were in cardiac and vascular surgery Cardiovascular and bleeding complications following orthopedic surgery is lacking

4 Background Do We Care About Myocardial Necrosis? Why measure troponin perioperatively? 1. Silent ischemia 2. Asymptomatic 3. Anesthesia may blunt symptoms 4. May impact short- and long-term prognosis Troponin and Survival following Major Vascular Surgery Landesberg G et al. Circulation 2009;119:

5 Background Do We Care About Major Bleeding? All-Cause Mortality (%) Why Evaluate Bleeding? 1. Transfusions are not benign 2. May require reoperation 3. May augment ischemia 4. May prevent use of antithrombotics 5. May impact short- and long-term prognosis Bleeding and Survival Cumulative Incidence of All-cause Mortality (%) No Severe/Moderate Bleed Severe/Moderate Bleed Month Month Berger JS, et al. Am Heart J 2011;162:98-105

6 Objectives 1. Investigate incidence of thrombotic and bleeding events following orthopedic surgery 2. Identify independent risk factors for perioperative adverse events 3. Compare outcomes in subjects with CAD vs without CAD 4. Evaluate use of perioperative aspirin

7 Methods Inclusion Criteria: > 21 yrs knee, hip, spine surgeries November 2008-December separate hospitals Reviewed all ICD-9 coded data (n=3,083) and all charts for CAD subjects (n=327) Variables: baseline demographics, CV risk factors, medications, transfusion data, outcomes

8 Outcome Variables Myocardial necrosis: troponin > 99 th % Major bleeding: ISTH guidelines* Fatal Symptomatic Hgb > 2 g/dl >2 U transfusion w/in 48 hours Repeat intervention or prolonged hospitalization MI/Postop Hemorrhage/Stroke: ICD-9 coding *Schulman, S., et al., Definition of major bleeding in clinical investigations of antihemostatic medicinal products in surgical patients. J Thromb Haemost, (1): p

9 Statistical Analysis Baseline characteristics and outcomes were compared using Pearson Chi-Square test Multivariable logistic regression to identify independent predictors P-value < 0.05 was considered significant SPSS version 13.0 was used for calculations

10 Overall Results 3,083 subjects Mean age 60.8±13.3 yrs 59% female 65% Caucasian 94% elective surgery

11 Overall Results Medical Comorbidities Subjects (n=3,083) HTN 1,513 (49) Diabetes 447 (14) CAD 327 (11) CKD 82 (3) Cancer 69 (2) COPD 69 (2) PVD 23 (1) Orthopedic Procedures Subjects (n=3,083) Spine 1,161 (38) Knee 1,001 (32) Hip 920 (30)

12 Adverse Events in Overall Population

13 Independent Predictors of Myocardial Necrosis Wald OR Age ( ) CAD ( ) Cancer ( ) CKD ( ) PVD ( ) COPD ( ) DM ( ) HTN ( )

14 Independent Predictors of Major Bleeding Wald OR Cancer ( ) Female Sex ( ) CAD ( ) COPD ( ) PVD ( ) Age ( ) CKD ( ) HTN ( ) DM ( )

15 % of Subjects Subjects with CAD had increased CV events Myocardial necrosis P<0.05 2,5 2 1,5 Coded MI 2,1 P< ,5 0,5 0 CAD No CAD

16 % of Subjects Subjects with CAD had increased bleeding ISTH Bleeding P<0.05 2,5 2 1,5 Coded Bleeding 2,1 P< ,5 0,7 0 CAD No CAD

17 CAD subjects are at increased risk of perioperative events 53% aspirin use at baseline 7.6% aspirin use w/in 3 days of surgery Independent predictors of aspirin use: Older age History of MI There was no significant association between aspirin use and either thrombotic or bleeding complications

18 Discussion The incidence of myocardial necrosis and ISTH major bleeding differs according to its definition Incidence of myocardial necrosis and major bleeding >5% Significant adverse consequences of troponin in the peri-op setting Long-term consequences of major bleeding in the peri-op setting remains unknown It is essential to understand the tradeoff between thrombotic and bleeding complications in this setting

19 Limitations Observational study and therefore many confounders may exist Data is limited to variables captured by ICD-9 coding Troponin was not measured in all subjects and there was no uniform time assessment ISTH bleeding definition: used 1 calendar day instead of 48 hours Aspirin use was only recorded in CAD subjects and was ascertained by chart review

20 Conclusions There is a significant risk of both thrombotic and bleeding complications following orthopedic surgery CAD, cancer, and PVD were predictors of both thrombotic and bleeding events Age and CKD predicted thrombotic complications Female sex and COPD predicted bleeding complications There was a low prevalence of peri-op aspirin use in CAD patients undergoing orthopedic surgery Future studies investigating the trade-off between thrombotic and bleeding complications following orthopedic surgery and the potential use of aspirin are warranted

21 Thank You Questions?