Perioperative Myocardial Infarction Which patient should UNDERGO CORONARY ANGIOGRAPHY? The Cardiologists view Hans Rickli, St.Gallen 1
Experience Standards Risk stratification Team approach.. Tightrope walk beetween
Z.W.,1943 Elective thrombendarterectomy right femoral artery January 7, 2015 PAOD Stad II b right leg cardivascular risk profile (smoker, hypertension, dyslipidemia) Pre-operative assessement without signs of relevant ischemia (Myocardial perfusion scintigraphy) Intraoperative: extensive bleeding., massive transfusion of 10 Units of RBC ICU Extubation on January 8 in the early morning 18.06.2015
18.06.2015 Serum- Chemie
18.06.2015 12-lead ECG Jan 8, 2015: 9.28h
Z.W.,1943 Elective thrombendarterectomy right femoral artery January 7, 2015 PAOD Stad II b right leg cardivascular risk profile (smoker, hypertension, dyslipidemia) Preoperative assessement without signs of relevant ischemia Intraoperative extensive bleeding., Transfusion of 5 l RBC ICU Extubation on January 8.. some chest discomfort. 18.06.2015
Standards 18.06.2015
Repeat 12-lead ECG Jan 8 : 3 hrs later 18.06.2015 hemodynamically unstable: Syst BP 95/60 mm Hg
L.CH.HC.11.2011.0079-EN Knowledge - skills 12
Biccard B. Curr Opin Anesthesiol 2014, 27:336 343 Prevalence and clinical significancs of the ECG ~ 23-62% ~ 16-(50)% ~ 2-6% ~ 0,5-7.5% VISION trial: new postop. ST-elevation, LBB und ECG-changes of the anterior wall associated with elevated 30 d mortality in case of elevated troponin
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most important modality in the acute setting Rapidly and widely available LV systolic function important prognostic variable in patients with CAD. In experienced hands, transient segmental hypokinesia or akinesia may be detected during ischaemia
Standards Eiger Mönch - Jungfrau
First steps O2 12-Lead ECG, hs-troponin initial and after 3 hours Nitroglycerin s.l. 0.4 bis 0.8mg, Nitroderm transderma 5-10mg (if syst BP > 100 mm Hg) Analgesia Correction of anemia (Hb > 8 g/l) and hypovolemia Antitrhombotics? Local Guidelines KSSG 2015
Risk stratification Team approach (Aletsch-Gletscher)
Extended measures: Persistence of symptoms, ECG changes, hemodynamic instability Risk stratification (anesthiologist, surgeon, cardiologist) Team approach Decision of coronary angiography Antithrombotic therapy Local Guidelines KSSG 2015
Extended measures : modified ACS-scheme ASS 100mg od, usually no loading-dose Heparin: Start with 10 000 15 000 (- 20 000) IE/d; no Bolus Dual Antiplatelet therapy? Individual (patient) and interdisciplinary (cardiologist, surgeon, anesthiologist, ICU specialist. the experienced ones..) Local Guidelines KSSG 2015
Extended measures:. Think about peridural anesthesia Timing of removal of peridural catheters in case of Clopidogrel (Plavix ), Prasugrel (Efient ) or Ticagrelor (Brilique ) Alternative solution: iv. (reversible) GP IIb/III a inhibitor Tirofiban (Aggrastat ) Local Guidelines KSSG 2015
Extended measures: Persistence of symptoms, ECG changes, hemodynamic instability Hemodynamically stable patients (syst BP > 100mmHg) i.v. Nitrolgycerin perfusion (start with 10-20 µg/min) target BP: syst. 110-130mmHg. «Careful» betablockade with metroprol 1mg i.v. (max. 5 mg), target heart rate 70-80 bpm no initiation with betablocker in case of heart failure Hemodynamically stable patients and for risk stratification Echocardiogaphy (transthoracic or transoesophageal (intraoperatively)) Local Guidelines KSSG 2015
Recommendations for invasive evaluation and revascularization in NSTEMI
Standardized approach?
Biccard B: Curr Opin Anesthesiol 2014, 27:336 343
Severe left Main stenosis - several stenosis of LAD and LCX treated with DES Right radial approach
18.06.2015 Serum- Chemie
Association between postoperative troponin levels and 30 day mortality Devereaux PJ, Chan MT, Alonso-Coello P, et al. Association between postoperative troponin levels and 30- day mortality among patients undergoing noncardiac surgery. JAMA 2012; 307:2295 2304.
Prevalence of myocardial injury in the perioperative setting in VISION MINS: 8 % 12.5% In case of perioperative Troponin elevation exclude «non-cardiac» triggers for myocardial injury
Myocardial Injury after Noncardiac Surgery international, prospective cohort study of 15,065 patients 30-day Mortality in patients with Troponin > 0.03 ng/ml Prevalence n (%) 30 day mortality N (%) MINS 1200 (8%) 115 (9.6%) Sepsis/infection 1714 (11.4) 96(11.8%) Infection 15 (1.7%) Stroke 81 (0.5%) 16 (19.8%) Pulmonary embolism 95 (0.6%) 11 (11.6%) «multifactorial or indeterminate myocardial injury» after noncardiac surgery associated with bad prognosis The Vascular events In noncardiac Surgery patients cohort evaluation (VISION) Writing Group, Anesthesiology 2014; 120:564-78
Biccard B: Curr Opin Anesthesiol 2014, 27:336 343 Which further management?
Controversy/Dilemma: Which subgroup of the MINS should therefore undergo coronary angiography? Perioperative ACS: Similar management as in the setting without non-cardiac surgery STEMI, NSTEMI mit ST-depression and recurrent symptoms Antithrombotics: Modification according to surgical circumstances (postoperative bleeding risk) All other «MINS»? invasive approach as much as possible for further risk stratification (coronary angiography revascularization)?
Consens: What we know about Myocardial Infarction in Noncardiac Surgery (MINS) MINS is common (8%) and associated with bad prognosis 1 of 10 pts with MINS will die within 30 days Subgroup with elevated risk within MINS population (elderly, ST-elevation, new LBB, preop. Risk Factors)
Controversy/Dilemma: Which subgroup of the MINS should therefore undergo coronary angiography? What we don t know: Evidence based strategy for a conservative or invasive approach Therefore: urgent need for clinical trials to establish strategies to prevent and treat this important complication Do more (as much as possible) coronary angiography for further risk stratification and clarify between type I/II and other myocardial injury
Thank you! 39
Controversy/Dilemma: low class of recommendation. Perioperative monitoring with Troponin? European Heart Journal (2014) 35, 2383 2431: ESC Guidelines on Non-Cardiac surgery
3 C s: Confusion: Definition of perioperative MI The 3 «MI s» Myocardial Infarction Myocardial Ischemia Myocardial Injury Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD et al. Third universal definition of myocardial infarction. Eur Heart J 2012;33:2551 2567.
Confusion: Definition of perioperative MI The 3 «MI s» Myocardial Infarction Myocardial Ischemia Myocardial Injury Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD et al. Third universal definition of myocardial infarction. Eur Heart J 2012;33:2551 2567.
Do you know which test you are using? (H)s-cTn improve sensitivity to dectect myocardial injury
Hs-cTn: quantitative marker the higher the sensitivity, the lower the specificity Mueller C. Eur Heart J 2014
Definition of periop. Myocardial Infarction Elevated cardiac biomarker level Devereaux PJ, et al. Ann Intern Med 2011; 154: 523-8
Elevated cardiac biomarker level Devereaux PJ, et al. Ann Intern Med 2011; 154: 523-8
Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac surgery Meta-analysis 1 : HR 6.7 (4.1,10.9) Association between postoperative troponin levels and 30-day mortality among patients undergoing noncardiac 2 Ischemic non-ischemic? 1. Levy M, et al. Anesthesiology 2011; 114: 796-806 2. Devereaux et al. JAMA 2012; 307:2295 304
Myocardial Injury after Noncardiac Surgery international, prospective cohort study of 15,065 patients 15 065 patients aged 45 yr or older in-patient noncardiac surgery troponin T (TnT4) measured during the first 3 postoperative days Patients with a troponin T level of 0.03 ng/ml or greater (elevated abnormal laboratory threshold) assessed for ischemic features (i.e., ischemic symptoms and electrocardiographyfindings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded The Vascular events In noncardiac Surgery patients cohort evaluation (VISION) Writing Group, Anesthesiology 2014; 120:564-78
Myocardial Injury after Noncardiac Surgery international, prospective cohort study of 15,065 patients MINS (Myocardial Injury after Noncardiac Surgery)- Definition: Troponin > 0.03ng/ml & absence of Sepsis/Infection, Stroke, pulmonary embolus ( excluded group ) The Vascular events In noncardiac Surgery patients cohort evaluation (VISION) Writing Group, Anesthesiology 2014; 120:564-78
Ischemic features of Patients suffering MINS: low prevalence of symptoms and ECG changes The Vascular events In noncardiac Surgery patients cohort evaluation (VISION) Writing Group, Anesthesiology 2014; 120:564-78 1 of 6 pts with ischemic symptoms 1 of 3 pts with ECG changes
Ischemic features of Patients suffering MINS: Outcome 1 of 6 pts die within 1 month 1 of 6 pts die within 1 month The Vascular events In noncardiac Surgery patients cohort evaluation (VISION) Writing Group, Anesthesiology 2014; 120:564-78
The Vascular events In noncardiac Surgery patients cohort evaluation (VISION) Writing Group, Anesthesiology 2014; 120:564-78 Ischemic features of Patients suffering MINS: Facts Myocardial Infarction Only 41.8% of pts with MINS fulfilled the universal definiton of Myocardial infarction Myocardial Ischemia: A minority of pts with MINS with ischemic symptoms Myocardial Injury Among the 58.2% who did not experience ischemic symptoms 1 in 13 died within 30 days
The Vascular events In noncardiac Surgery patients cohort evaluation (VISION) Writing Group, Anesthesiology 2014; 120:564-78 Controversy/Dilemma: Which subgroup of the MINS should therefore undergo coronary angiography? Independent Predictors of 30-day Mortality within MINS