Perioperative Myocardial Infarction · 2018-11-16 · Perioperative Myocardial Infarction In the elderly Giora Landesberg MD, DSc, MBA Associate Professor Director, Cardiothoracic

Perioperative Myocardial Infarction

In the elderly

Giora Landesberg MD, DSc, MBA

Associate Professor

Director, Cardiothoracic & Vascular

Anesthesia

Hadassah Medical Center

Jerusalem ISRAEL

3rd International Symposium: Perioperative Care for Seniors (2015)

The dominant paradigm:

Vulnerable plaque

Plaque rupture / erosion

Acute coronary syndrome

ST-elevation non-ST-elevation


ST

ST Necrosis by closed

Muscle

Necrosis by closed

Artery

Arrhythmias

CHF Death

CM Gibson 2002

non-ST-elevation versus ST-elevation MI


The majority of myocardial

infarctions occur in relatively

non-occluding coronary plaques

(<50% stenosis)

Falk E, Shah P & Fuster V. Circulation. 1995;92:657-671


Association of perioperative myocardial ischemia with cardiac morbidity and

mortality in men undergoing noncardiac surgery.

The study of Perioperative Ischemia Research Group

DT Mangano, WS Browner, M Hollenberg, MJ London, JF Tubau and IM Tateo

Perioperative ischemia is common (46%)

in high-risk patients undergoing major non-cardiac surgery

The majority of ischemic events are postoperative.

They are associated with postoperative cardiac

complications

The Holter monitoring era

New England J Medicine 1990;323:1781-8


Frank et al

J. Clin. Anesth. 1990;2:326-31.

PIRAT-I study

surgery

ST-trend

HR-trend


-6

-4

-2

0

2

4

6

5 10 15 20 25 30

-20

0

20

40

60

80

100

120

Time - (hours)

Heart

rate

- (

beats

/min

.)

HR and ST trends in a patient during CEA

ST-s

eg

men

t tren

d (m

m)

surgery

chest

pain

pulmonary

edema

ECG

64 yo lady

undergoes CEA

Background:

• IDDM

• TVD CAD

Perioperative Holter monitoring Prolonged postoperative ST-depression-type ischemia

CK-MB

elevation


% o

f p

ati

en

ts

151 major

vascular surgery

patients

Lancet 1993;341:715


3.9%

Most posto MI’s

are preceded by

prolonged ST-

depression, not

ST-elevation

Landesberg G.

Best practice and Research in

Anesthesiology 2005;19:77-95

1) Continuous on-line 12-lead ECG with

ST-segment monitoring (ST-Guard)

(starting before induction of anesthesia

until 2-3 days after surgery)

2) Cardiac troponins

(3 days postop.)

Mid 1990’s: Two new modalities


Β-blocker

PMH:

IHD, s/a CABG,

MI, reduced LVF

IDDM

HTN

PVD

s/a low-extremity bypass Sx.

MEDICATIONS:

atenolol, ACE-I, insulin,

aspirin

Case #1: 72 yo male

endarterectomyCarotid Surgery:


Prolonged postoperative

tachycardia-induced

ischemia on continuous

12-lead ECG

troponin elevation

Case #2 67 yo male

Surgery for Asymptomatic AAA (7.4 cm)

PMH:

• Hyperlipidemia, mild HTN, overweight

• quit smoking 12 yrs ago

• no history of IHD

• SOB on moderate exertion

Echocardiography

• LV & RV normal size and hyperfunction

• MV – moderate regurgitation

• Otherwise normal valves


LCX

LAD

RCA

Bisoprolol P.O.

for 1 month prior to the surgery

Surgery

Heart

rate

Surgery

Esmolol Heart

rate

Surgery

Esmolol

Prolonged

ischemia

Troponin-T

0.05

0.56

0.68

Prolonged postoperative tachycardia-induced ischemia on

continuous on-line 12-lead ECG

troponin elevation, but where is the plaque rupture?

Retrospective analysis of the

Cleveland Clinic registry:

1522 patients with preop. coronary angiography

21 hospital deaths or MI

42 matched controls

Am. J. Cardiology 1996

Duration of longest ST-depression type ischemia (min.)

r = 0.83

P = 0.0000

185 vascular

surgery patients

J. Am. Coll. Cardiol.

2001;37:1839-45

The major role of tachycardia

* * *

185 vascular

surgery patients


2001;37:1839-45


Onset of longest ischemia from the end of surgery (hrs)

1 0

8

6

4

2

0 0 5 10 15 20 25 30 35

All longest ischemic events

Events leading to myocardial infarction

Nu

mb

er

of

eve

nts

Timing of postoperative ischemia

185 vascular

surgery patients


2001;37:1839-45

Association with survival 447 major vascular

surgery patients

JACC 2003;42:1547-54

Troponin elevation after major vascular surgery is

common but is mostly silent !!

JACC 2003;42:1547-54


1,136 consecutive AAA patients

Abnormal cTnI concentrations were present in only 27% of all

patients with PMI at 6 h and in 93% by 48 h postoperatively.

Anesthesiology 2005;102:885-91

Coronary stenosis

70% 100% 50%

Plaque rupture – type MI

Prolonged, stress-induced ischemia – type MI

Inci

den

ce

J Cardiothoracic Vascular Anesthesia 2003;17:90-100

Universal definition of MI (Oct. 2007)

Circulation 2007;116:2634-53

Universal definition of MI (Oct. 2007)

Circulation 2007;116:2634-53

& prolonged tachycardia (increased heart rate) !!!

MI Myocardial

injury

Perioperative MI

is almost exclusively

type-II MI

Important definitions:

• Myocardial infarction – Rise and fall

of cTn >99th percentile in an ischemic

context (chest pain, ECG, etc.)

• Myocardial injury – Isolated cTn

elevation

Circulation 2009;119:2936-44


Prospective, multicenter (12 centers) 15,133 pts age ≥45, gen./reg. anesthesia cTnT measured at 6, 12hurs & pod 1,2,3 Outcome: 30 days mortality Peak TnT ≥ 0.02 ng/mL occurred in 11.6%

Can J Anesth 2012;59:1013-22

Without cTnI

With cTnI

Retrospective 2003-9, single center, Toronto

Of 51,701 pts 10,534 had cTnI measurements

Van Waes et al,

Circulation 2013

Single center cohort

2232 major nocardiac

surgery patients

Troponin-I on POD1-3,

19.4% had at least 1

troponin-I >0.06 ng/ml

Van Waes et al,

Circulation 2013

Single center cohort

2232 major nocardiac

surgery patients

Troponin-I on POD1-3,

19.4% had at least 1

troponin-I >0.06 ng/ml

Circulation,

Eur Heat J, 2012

JACC

Circulation 2009

;119:2936-44

Circulation 2009

;119:2936-44

Β-blocked

Not Β-blocked

Beattie et al.

Anesthesiology

2010;112:25-33

Retrospective analysis

of 4,387 noncardiac

surgery patients

Le Manach et al.

Anesthesiology

2012;117:1203-11

1,801 patients undergoing aortic

surgery

Documents

Perioperative Myocardial Infarction · 2018-11-16 · Perioperative Myocardial Infarction In the elderly Giora Landesberg MD, DSc, MBA Associate Professor Director, Cardiothoracic