Perioperative MI.ppt

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  • 1. Perioperative myocardial infarction after noncardiac surgery
    • INCIDENCE
    • 5.8% overall risk of postoperative cardiac death or major cardiac complications in patients undergoing major noncardiac surgical procedures [Goldman et al. NEJM 1977].
    • ~3% risk of perioperative MI in patients undergoing nonoperative surgery [Deveraux et al., CMAJ 2005]
    • Risk of 1.4%, 3.2%, to 6.9% in successive surgical patients [Mangano et al., NEJM 1995].
    • 1.8% incidence of perioperative MI in men over the age of 40, but ranging from 0% to 0.8% to 4.1% [Ashton et al., Ann Intern Med 1993].
    • High risk patients experienced perioperative MI 3.0% of the time [Mangano et al. NEJM 1990]
    • 4.7-5.6% incidence in patients with known coronary disease [Shah et al. Anesth Analg 1990; Badner et al. Anesthesiology 1998].
  • 2.
    • DIAGNOSIS
    • 14% patients have chest pain
    • 53% have a sign or symptom that triggers consideration for perioperative MI
    • Cardiac biomarkers
  • 3. Revised Goldman Cardiac Risk Index (RCRI)
    • Independent predictors of major cardiac complications:
    • High-risk operation (intraperitoneal, intrathoracic, suprainguinal vascular procedures)
    • Hx of ischemic heart disease
    • Hx of heart failure
    • Hx of cerebrovascular disease
    • DM requiring insulin
    • Preoperative serum creatinine > 2.0 mg/dL
  • 4.
    • Deveraux et al., CMAJ 2005:
    • Rate of cardiac death MI, and cardiac arrest:
    • 0 RF: 0.4% [0.1-0.8]
    • 1 RF: 1.0% [0.5-1.4]
    • 2 RF: 2.4% [1.3-3.5]
    • 3+RF: 5.4% [2.8-7.9]
    Revised Goldman Cardiac Risk Index (RCRI)
  • 5.
    • Auerbach et al. Circulation 2006:
    • Rate of cardiac death, MI, cardiac arrest or VF, pulmonary edema, complete heart block, without or with perioperative beta-blocker treatment:
    • 0 RF: 0.4-1.0% vs. <1.0%
    • 1-2 RF: 2.2-6.6% vs. 0.8-1.6%
    • 3+ RF: >9% vs. >3%
    Revised Goldman Cardiac Risk Index (RCRI)
  • 6. Diagnosis of perioperative MI after noncardiac surgery
    • No standard diagnostic criteria. Diagnosis complicated by lack of symptomatic presentation in about half of patients with perioperative MI.
    • Deveraux et al, CMAJ 2005 proposed the following diagnostic criteria:
    • 1) rise in troponin (or fall after an elevated value) plus one or more of
      • Ischemic signs or symptoms (e.g., SOB)
      • New pathologic Q waves on ECG
      • Coronary artery intervention
      • New wall motion abnormality or fixed defect on echo or myocardial perfusion imaging
    • 2) new pathologic Q waves on ECG in patients without troponin measurements
  • 7.
    • Study: 108 patients (96 vascular and 12 spinal procedures)
      • Blood samples q6h for 36h post-surgery
      • Daily ECG
      • Baseline and day 3 echocardiogram
    • Of 8 patients with new wall motion abnormalities, 8 had elevated troponin I; 6 had elevated CK-MB. False positives included 1 with elevated troponin I and 19 with elevated CK-MB
    Diagnosis of perioperative MI after noncardiac surgery
  • 8. Prognosis of perioperative MI after noncardiac surgery
    • 15-25% in-hospital mortality, of which perioperative MI accounts for 2/3
    • Nonfatal perioperative MI predisposes to death, ACS, or progressive angina:
      • Post-op troponin I > 1.5 mcg/L: increased 6-mo mortality (OR 5.9)
      • Post-op troponin I > 0.6 mcg/L: increased 32-mo mortality (OR 2.15)
  • 9. Role of perioperative beta-blockers in mortality risk
    • 2006 retrospective study of 663,665 adults undergoing major noncardiac surgery. 18% received beta-blockers (14% RCRI-0, 44% RCRI-4+).
    • RCRI 0: 1.4% mortality, OR 1.36 [1.27-1.45]
    • RCRI 1: 2.2% mortality, OR 1.09 [1.01-1.19]
    • RCRI 2: 3.9% mortality, OR 0.88 [0.80-0.98]
    • RCRI 3: 5.8% mortality, OR 0.71 [0.63-0.80]
    • RCRI 4+: 7.4% mortality, OR 0.58 [0.50-0.67]
  • 10. Choice of beta-blocker agent for perioperative administration
    • Cardiovascular benefit of perioperative beta-blockers has only been demonstrated for beta-adrenergic receptor 1-selective antagonists, such as atenolol or metoprolol.
    • Retrospective cohort analysis (Redelmeier BMJ 2005) of treatment with atenolol vs. metoprolol in elderly indicated a decreased rate of death or MI after treatment with atenolol relative to metoprolol (2.5% vs 3.2% mortality).
    • Although nonselective agents such as propanolol are not initiated for perioperative therapy due to adverse pulmonary and peripheral arterial effects, patients on long-term propanolol use do not need to switch agent perioperatively.
  • 11. Timing of beta-blocker administration
    • Auerbach JAMA 2002 meta-analysis of timing of administration (from 1 mo prior to while in the PACU):
    • beta-blocker therapy should begin before surgery and should be continued at least through hospitalization.
    • Rapid cessation should be avoided.
  • 12. Adverse effects of perioperative beta-blocker administration
    • Bradycardia requiring atropine treatment is reported in >20% patients receiving perioperative beta-blockers.
    • Withdrawal may lead to adrenergic hypersensitivity, associated with accelerated angina, MI, or cardiovascular mortality.
    • Beta-adrenergic receptor 1 antagonist agents are generally safe and can be tolerated by patients with severe COPD or or reactive airway disease.
  • 13. Recommendations for perioperative beta-blocker therapy
    • For RCRI>2, Beta-1 selective agent, begin as an outpatient up to 30 d prior to operation, titrating to HR 50-60 BPM.
    • Longer-acting agent (atenolol or bisoprolol) may be more effective than shorter-acting agent (metoprolol).
    • No data for duration of therapy—suggest continuing for 1 month after surgery.