Risk For MI After Arthroplasty Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul...
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Transcript of Risk For MI After Arthroplasty Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul...
Risk For MI After Arthroplasty
Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul
Supervise by Assoc.Prof. Sirilak Suksompong
• A 81 year-old man• Admit for Elective total hip replacement• Underlying disease : HT on Atenolol (50) 1x1 DLP on Simvastatin (20) 1x1 Old CVA 4year ago (full
recovery) Previous MI 11 months ago • Choice of anesthesia : GA with ETT• Intraoperative : no complication• POD 7 : typical angina , ECG CK-MB 2.7 (0-3ng/ml), Trop-T 1.78(0-
0.2ng/ml) Imp NSTEMI
Postoperative MI ?
• Acute Myocardial Infarction• Definition
• Detection of and/or of cardiac biomarker values (preferably cardiac troponin) with > value above the 99th
percentile upper reference limit and with > one of the following :
Circulation, published online August 24,2012;2012 American Heart Association,Inc.
• Symptoms of ischemia• New or presumed new significant ST-T
changes or new LBBB• Development of pathological Q waves in
ECG• Imaging evidence of new loss of viable
myocardium or new regional wall motion abnormality
• Identification of an intracoronary thrombus by angiography or autopsy
Circulation, published online August 24,2012;2012 American Heart Association,Inc.
• LBBB
• Postoperative Myocardial Infarction• Often recognized late (postoperative day 3
- 5), resulting in high (30% - 70%) mortality
Morbidity and Mortality Incidence
From Anesthesiologist records in last year
9 case
Diagnosis Operation
Corneal ulcer with perforation LE
AMT patch with CT LE
Submandibular gland tumor Fibular free flap
BPH TUR-BT
AAA EVAR
ESRD AVF
Acute appendicitis Appendectomy
Perianal abscess I&D
CA larynx Total laryngectomy
SAH Craniotomy
Perioperative MI
Myocardial InfarctionVS
Total Hip or Knee Replacement
Study Year
No. of patien
ts
%Post-MI
F/U Design
Mantilla et al.
2002
10,244 0.4 30 d cohort
Gandhi et al.
2006
3,471 1.8 30 d retrospective
Parvizi et al.
2007
1,636 0.37 6 wk
cohort
Pulido et al.
2008
15,383 0.27 D/C cohort
Khatod et al.
2008
17,080 0.1 90 d retrospective
• Limitation such as • small sample sizes• lack of matched control • only focused on short-term • no analysis for medication
Strengths
• The nationwide population-based design• Large sample size• Information on matched controls• Completeness of follow-up
• Nationwide matched control retrospective cohort study
• The Danish national registries
Inclusion criteria
• Patients who underwent a primary THR or TKR surgery
• January,1998 to December, 2007• Age 18 years or older
Exclusion criteria
• Prior AMI within 6 weeks before
95,664 Patients
THR group (n=66,524
)
TKR group (n=28,703
)
Control group
(n=86,164)
Control group
(n=200,001)
Followed up until - Death- Migration- Revision THR or TKR- End of study period- Acute myocardial
infarction
437 patients excluded
Thromboprophylaxis
Thromboprophylaxis
• Incidence of acute myocardial infarction• Potential risk factors
• Age • Sex • History of AMI, heart failure,
cerebrovascular disease • Drug dispensing within 6 months
F/U time(yr) Male(%) Age,mean(yr)
IHD (%) CHF (%)0
10
20
30
40
50
60
70
80
3.9
36.9
71.9
12.57.9
4.1
36.9
71.9
10.56.5
Exposed(n=66,524) Unexposed(n=200,001)
Baseline Characteristics of patients Undergoing THR and Matched control
NSAIDs B-Blockers Statins Antiplatelet0
10
20
30
40
50
6050.7
13.28.7
22.3
16.412.1
8.7
20.9
Exposed (n=66,524) unexposed (n=200,001)
Drug use within previous 6 mth (%)
2 weeks
6 weeks
THR TKR0
5
10
15
20
25
30
2.41 2.26
12.4
9.2
25.3
11.2
18-59yr 60-79yr >80yr
Adjusted HR(6-wk risk for AMI)
Effect Modifiers of AMI risk after THR or TKR vs Matched controls
Adjusted HR (6wk risk for AMI)
THR TKR
Previous MI 2.12 (1.59-2.83) 1.15 (0.55-2.42)
1.5-6 mo before
4.25 (2.24-8.05) 4.14 (0.91-18.87)
6-12 mo before 3.82 (1.90-7.67) 2.18 (0.28-16.79)
>12 mo before 1.91 (1.40-2.59) 0.96 (0.43-2.17)
Adjusted HR (6wk risk for AMI)
THR TKR
NSAIDs 1.80 (1.31-2.47)
1.64 (0.78-3.42)
B-Blockers 1.45 (1.11-1.88)
1.49 (0.82-2.67)
Platelet inhibitors 1.33 (1.03-1.73)
2.30 (1.21-4.37)
Adjusted HR (6wk risk for AMI)
THR TKR
Heart failure 2.47 (1.90-3.20)
3.75 (2.01-6.98)
Cerebrovascular disease
2.06 (1.57-2.70)
2.09 (1.05-4.15)
MarrowEmbolization
AntithromboticAgents
Limitations
• Lack of information on other risk factors for AMI• smoking, blood pressure, biochemical
variables, and BMI• No information on inpatient anticoagulant
use• No information about GA or RA
GA vs RA
• General anesthesia vs Regional anesthesia showed a trend toward only 1.4 fold increase risk of AMI
Anesthesia for hip fracture surgery in adults (Review)2004 The Cochrane Collaboration
• Increase risk of AMI during the first 2 weeks after arthroplasty
• AMI within 1 year should be contraindication for undergoing elective THR surgery
• Prophylactic therapy• Adrenergic Blockers• Statins• Calcium channel Blockers• 2 Agonists• Aspirin
• Prophylactic therapy• Adrenergic Blockers
• Long term should not be discontinued• No study has compared prophylactic B-
Blockade with short term
• Prophylactic therapy• Adrenergic Blockers• Statins
• Abrupt withdrawal cause plaque destabilization
• Reduced perioperative and long term cardiac complication
• Large randomized controlled trials are still needed
Perioperative Management• Correct tachycardia, hypertension,
hypotension, and pain• Tight hemodynamic monitoring• Blood transfusion in patients with CAD and
Hb<10• Coronary intervention and antithrombotic
therapy
Take Home Messages• New definition of AMI • THR and TKR patients increased risk of AMI
during the first 2 weeks after surgery• Elective THR and TKR should be
contraindicated in patients with previous MI in last 1 year before
• Management for decrease risk of postoperative MI are necessary
THANK YOU