Perioperative Myocardial Infarction M M Case Dr. Gordon

54 y/o female for left total hip arthroplasty M&M May 2005 Which statement about postoperative myocardial infarction (PMI) is MOST likely true? A. Most PMIs occur on the fifth postoperative day B. Most PMIs are Q-wave infarctions C. Thrombosis caused by plaque fissure is the main mechanism of PMI D. PMIs are frequently associated with prolonged postoperative silent ischemia ASA SEE Vol21A #86, 2005 The BEST strategy to reduce perioperative cardiac complications in a patient undergoing elective major vascular surgery within the next week is A. preoperative percutaneous transluminal coronary angioplasty (PTCA) B. use of a pulmonary artery catheter C. coronary artery bypass grafting D. perioperative beta-blocker therapy ASA SEE Vol21A #31, 2005 Which statement about diabetes mellitus and its perioperative management is MOST likely true A. About 10% of patients with type 2 diabetes mellitus do not know that they are diabetic at the time or surgery. B. Current recommendations prior to major surgery are to obtain a stress test for diabetic patients who have one other risk factor (smoking, hypercholesterolemia, hypertension, family history of coronary artery disease, or males 40 years of age). C. In a 70 kg patient, one unit of regular insulin given intravenously will lower the glucose by approximately 25-30 mg/dL. D. Thiazolidinediones such as rosiglitazone (Avandia) or pioglitazone (Actos) increase insulin production. ASA SEE Vol21A #87, 2005 History Medical osteoarthritis left hip pain score 9 -10 HTN DM II w/o complications lumbar spinal stenosis Surgical - none Allergies – none known Medications insulin (Humulin 70/30) 40 U a.m./36 U p.m. (20 U a.m. of surgery) metformin 500 mg BID lisinopril 40 mg QD hydrochlorothiazide 25 mg QD ibuprofen 800 mg TID prn acetaminophen/hydrocodone 500/5 mg Q4-6H prn acetaminophen/codeine 325/5 mg Q6H prn ROS Exercise capacity 4-10 METS Heartburn/indigestion Physical Exam Wt 76 kg Ht 155 cm BMI 31.6 BP 134/77 P 99 R 16 T 37 SpO2 97 Alert Left hip pain Airway – no problem Cardiopulmonary – within normal limits Laboratory Hct 43 Blood glucose 97 Questions Are you sure I have coronary artery disease? Do we need to evaluate before my hip surgery? What is risk of hip surgery now? If CAD, would CABG first reduce my risk? Should I get a beta blocker now? http://metrohealthanesthesia.com/presentations/ Perioperative Evaluation and Treatment of the Cardiac Patient Undergoing Noncardiac Surgery November 4, 2003 Thomas Vrobel, M.D. Antonio Cooper, M.D. with thanks to Robert Finkelhor, M.D. BETA-BLOCKERS UNKNOWN FACTORS What is the optimal dose? How frequent are complications? Who should receive therapy? Are all beta blockers effective? When should they be started? How long should they be used? Are Alpha-Blockers also effective? Should beta blocker be added to lisinopril just before induction? Bertrand M. Should the Angiotensin II Antagonists be Discontinued Before Surgery? Anesthesia and Analgesia 92:26-30, 2001 “A severe hypotensive episode, requiring vasoconstrictor treatment, occurs after induction of general anesthesia in patients chronically treated with AIIA. Recommendations to discontinue AIIA drugs on the day before the surgery may be justified.” Comfere T et al. Angiotensin System Inhibitors in a General Surgical Population Anesth Analg 2005;100:636-644 In conclusion, discontinuation of ACEI/ARA therapy at least 10 h before anesthesia was associated with a reduced risk of immediate postinduction hypotension. Intermediate Clinical Predictors • Remote MI ( >1 month) • Stable angina • Compensated CHF • Creatinine  2.0 • Diabetes Functional Capacity Metabolic Equivalents (METs) • • Intermediate (4-10 METs) • Excellent (> 10 METs) Climbing a flight of stairs Low (< 4 METs) Level walking at 4 mph Scrubbing floors – increased surgical risk Moving heavy furniture Golf Surgery Specific Risk Intermediate (1-5% Mortality) • Intraperitoneal /intrathoracic • Orthopedic • Head & neck • Carotid endarterectomy EBL for THA at MHMC, last 13 Cases (excluded: revisions and one outlier 10L EBL) Surgeon B.P. J.S. J.W. R.W. H.V. EBL 300 900 900 250 350 300 200 600 350 300 1500 400 50 MEAN 492 ml G.Gordon 2005 Operative Risk Stratification Clinical Predictors Major < 4 METs Stress Testing High OR Intermediate Minor/none > 4 METs Surgical Procedural Risk Intermediate or Low Answers Coronary artery disease? Uncertain, but probably yes Evaluate before or after hip surgery? After Risk of hip surgery? <5% CABG before or after hip surgery? After, if indicated Beta blockers? Maybe after induction if not hypotensive or bradycardic Intraoperative course Moderate hypotension after induction and intermittently throughout with Hemorrhage with EBL 1725 ml associated with 1-2 mm ST depression (with tachycardia) that resolved after RBC transfusion PACU BP 123/65 P 98 R 11 ECG Cardiology New chest pain relieved by NTG Postop (hours) CK-MB 7 6 5 4 3 2 1 0 0 8 16 30 38 CK-MB Diagnosing Perioperative MI • Often without typical angina • 2/3 present with ST depression • CK-MB/Troponins • ECG/Troponin (high risk patients) – q 8 h first 24 hrs then – next 2 days Peak Cardiac Troponin I in Patients with and without PMI (based on postop change in echocardiographic wall motion) Adams JE et al. Diagnosis of Peroperative Myocardial Infarction with Measurement of Cardiac Troponin I. NEJM 330(670-674), 1994 Postop (Day One) Echocardiogram Normal right and left ventricular size and function (no wall motion abnormality) Left ventricular ejection fraction 75% Postop MI? Cardiac catheterization? Postop (hours) Troponin I 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 8 16 30 38 42 Troponin I Troponin I Proposed MI cutoff levels 3.1 (JAmCollCardio 42:2547-54, 2003) 2.5 (ClinCardiol 20:269-71, 1997) 2.0 (ClinChem 45:206-12, 1999) 1.5 (Circulation 106:2366-71, 2003) 1.5 (Anesthesiology 102:885-891, 2005) Postop (hours) Troponin I 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 8 16 30 38 42 Troponin I Postop MI? yes Cardiac catheterization? yes Catheterization (postop day 6) report Normal LV systolic function LMCA - Normal LAD - Severe diffuse disease. Multiple 70-90% stenoses mid and distal. Cx - Severe diffuse disease RCA - Severe diffuse disease CABG 5 weeks postop Post CABG (hours) CK-MB 17.5 17 16.5 16 15.5 15 14.5 14 13.5 7 12 CK-MB Post CABG (hours) Troponin I 8 7 6 5 4 3 2 1 0 1 7 12 Trop I McFalls EO et al. Coronary artery revascularization before elective major vascular surgery. NEJM 351:2795-2804, 2004 510 patients with stable CAD randomized to CABG or no CABG before major vascular repair (of AAA or vascular occlusive disease to legs) No difference in incidence of postop vascular surgery MI (13%) No difference in long-term mortality (22% over 2.7 years) “coronary artery revascularization before elective vascular surgery among patients with stable cardiac symptoms cannot be recommended” Which statement about postoperative myocardial infarction (PMI) is MOST likely true? A. Most PMIs occur on the fifth postoperative day B. Most PMIs are Q-wave infarctions C. Thrombosis caused by plaque fissure is the main mechanism of PMI D. PMIs are frequently associated with prolonged postoperative silent ischemia ASA SEE Vol21A #86, 2005 The BEST strategy to reduce perioperative cardiac complications in a patient undergoing elective major vascular surgery within the next week is A. preoperative percutaneous transluminal coronary angioplasty (PTCA) B. use of a pulmonary artery catheter C. coronary artery bypass grafting D. perioperative beta-blocker therapy ASA SEE Vol21A #31, 2005 Which statement about diabetes mellitus and its perioperative management is MOST likely true A. About 10% of patients with type 2 diabetes mellitus do not know that they are diabetic at the time or surgery. B. Current recommendations prior to major surgery are to obtain a stress test for diabetic patients who have one other risk factor (smoking, hypercholesterolemia, hypertension, family history of coronary artery disease, or males 40 years of age). C. In a 70 kg patient, one unit of regular insulin given intravenously will lower the glucose by approximately 25-30 mg/dL. D. Thiazolidinediones such as rosiglitazone (Avandia) or pioglitazone (Actos) increase insulin production. ASA SEE Vol21A #87, 2005