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Acute Coronary Syndrome in the Postoperative Period: Detection and Management

Dr Arun Kumar Consultant Cardiac Anesthesiologist Sheikh Khalifa Medical City Abu Dhabi

Objectives

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Background Recent advances Definition of MI Pathophysiology of perioperative MI Implications of perioperative MI and troponin release Diagnosis Management Conclusion

Postoperative MI!!

• Diagnosis- by ECG, Troponin • Management• Give Oxygen • Call Cardiologist
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Background

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Cardiac complications are the most common cause of postoperative morbidity and mortality in non-cardiac surgery 200 million non-cardiac surgeries annually worldwide 1 million die of perioperative MI within 30 days

Perioperative MI is associated with increased and and long term mortality

NEJM 1995. perioperative MI defined by rise in cardiac Troponin I seen in 27% of 377 patients scheduled for vascular surgery (McFalls et al.9% in those referred for thallium scan (Mangano. Lancet 2008. 371:1839) In CARP trial.1% at 30 days (Devereaux et al.4% in unselected patients >40 yrs to 6. 29: 394) . 333:1750) In POISE Trial of 8000 patients at increased cardiovascular risk incidence was 5. Eur Heart J 2008.Incidence of Perioperative MI • Varies with Definition of MI used Patient risk Population studied • • • • • • A 1995 review found a pooled average rate of 1.

100.Circulation 1999.Patient Related Risk. CXR) History of Cerebrovascular Disease (stroke / TIA) Use of insulin therapy Preop creatinine >175 micromol/L ( Lee et al.Revised Cardiac Risk Index History of IHD (MI. nitrates) History of CCF (history. q waves. S3 gallop. 1043-1049) . current chest pain. stress test. PND.

nonfatal MI. of risk factors 0 1 2 3 Risk of event 0.Risk of major perioperative cardiac event* No.4% 0.9% 7% 11% *cardiac death. nonfatal cardiac arrest .

Procedure Related Risk .

transient. specificity Thus postop MI was recognised late (day 3-5) with resultant high mortality (30-70%) Cardiac Troponin Assays have revolutionised detection and diagnosis of perioperative MI .MB limited sensitivity. ECG criteria. CK.What has changed? • • • • Previously MI defined by WHO criteria. cardiac enzymes (CK-MB) ECG criteria subtle.

The Troponins • Contractile protein in cardiac muscle • Myocyte damage releases cTn into serum • Detectable increase in troponin indicative of cardiac injury • cTn has nearly absolute myocardial tissue specificity and reflect even microscopic zones of myocardial injury • But all cTn rises are not due to ACS. troponin increase in isolation cannot be used to diagnose MI (Continuing Education in Anaesthesia. Critical Care & Pain Volume 8 (2) 2008 ) .

5th generation troponin assays available Each lab has its own cut off values!! & (Continuing Education in Anaesthesia.Troponins • 2000 consensus panel on MI defined cut off values • • 99th centile value of a normal population A measure of analytical precision. with a coefficient of variation of <10% • Until 2006 no commercial assays were capable of measuring troponin levels with this analytical precision • Now high sensitivity. Critical Care Pain Volume 8 (2) 2008 ) .

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ST-segment-T wave changes or new LBBB  New pathological Q-waves  Imaging evidence of new loss of viable myocardium or new RWMA  Identification of intracoronary thrombus by angio or autopsy (Third Universal definition of myocardial infarction. 2551-2567) .Definition of MI Detection of a rise and /or fall of cardiac biomarker values (preferably cardiac troponin) with at least one value above the 99th percentile of the upper reference limit (URL) and with atleast one of the following:  Symptoms of ischemia  New or presumed new sig. European Heart Journal (2012) 33.

European Heart Journal (2007) 28 2525-38 ) .(Universal definition of myocardial infarction.

Pathophysiology of Perioperative MI .

51:1913-1924 Copyright ©2008 American College of Cardiology Foundation. J Am Coll Cardiol 2008. et al. Restrictions may apply. .The Spectrum of Perioperative MI Poldermans. D.

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Circulation 2009. Landesberg G et al. The probability of type 1 and 2 MI as a function of the severity of CAD.Figure 3.119:2936-2944 Copyright © American Heart Association . The pathophysiology of perioperative myocardial infarction: facts and perspectives. Adapted from Landesberg G.

Implications of Perioperative MI and Troponin Release .

Circulation 2009.119:2936-2944 Copyright © American Heart Association .Figure 4. Landesberg G et al. Long-term survival of patients after major vascular surgery divided according to their highest troponin elevation obtained in the first 3 after days.

To examine characteristics and short term outcome of perioperative MI A cohort study from POISE trial 8351 patients from POISE Trial 4 cardiac biomarkers or enzyme assays measured within 3 days of surgery MI defined according to 2007 guidelines .

. 2011.From: Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery: A Cohort Study Ann Intern Med.154(8):523-528. All rights reserved. doi:10.1059/0003-4819-154-8-201104190-00003 Figure Legend: Defining Features of Perioperative MI Date of download: 10/5/2012 Copyright © The American College of Physicians.

From: Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery: A Cohort Study Ann Intern Med. 2011. doi:10.154(8):523-528. All rights reserved.1059/0003-4819-154-8-201104190-00003 Date of download: 10/5/2012 Copyright © The American College of Physicians. .

2% 65% of patients who had an MI did not have ischaemic symptoms Mortality similar between symptomatic and asymptomatic 58.30 day mortality higher for patients who had an MI than those who did not. 12% vs.3% of patients who had an MI died within 48hrs Median time to death in isolated enzyme rise group was 8 days Isolated enzyme rise after non-cardiac surgery also a predictor of mortality .

154(8):523-528. doi:10.From: Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery: A Cohort Study Ann Intern Med. 2011.1059/0003-4819-154-8-201104190-00003 Figure Legend: Independent Predictors of Perioperative MI Date of download: 10/5/2012 Copyright © The American College of Physicians. . All rights reserved.

beta-blockers. statins. ACE .aspirin.Change in practice? • • Highest risk for death after periop MI is in the first 48h Need for:  Quick diagnosis  Intense monitoring  Appropriate treatment  Secondary prophylaxis.

307(21):2295-22304 .The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study JAMA. 2012.

2 and 3 24 potential predictors of 30-day mortality recorded Primary outcome measure mortality at 30 days after surgery 15.. GA /RA.133 patients enrolled . elective. urgent or emergency non-cardiac surgery requiring overnight stay 4th generation Troponin 6-12 h postop and on day 1 . international cohort study from Aug 2007 to Jan 2011 >45 yrs.VISION Study • • • • • • • To determine relationship between the peak 4th generation troponinT measurement in the first 3 days after non-cardiac surgery and 30-day mortality A prospective.

2012.307(21):2295-2304. . All rights reserved.From: Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery JAMA. 2012.1001/jama.5502 Figure Legend: Date of download: 10/5/2012 Copyright © 2012 American Medical Association. doi:10.

03-0.16.3% • > 0.VISION Findings • Peak TnT values after noncardiac surgery strongest predictor of 30 day mortality • 41.9% • Median time to death from peak TnT value • 0.5 days • 0.02 ng/ml – 4% • 0.8% of deaths explained by elevated TnT • Absolute risk of 30-day mortality • TnT <0.29ng/ml.9.9 days .02ng/ml – 13.03 ng/ml.01ng/ml – 1% • 0.30.

VISION Study. statins . .Change in practice Monitoring TnT values for first 3 days after non-cardiac surgery substantially improves 30-day mortality risk stratification ? Intervention for at risk patients in the form of aspirin. rate control etc.

Diagnosis .

Perioperative MI. only 12% (London et al.1988) .all reasons for missing it ! • Mostly 48-72 h after surgery • Only about 14% of patients experience chest pain • Only 53% have clinical sign /symptom (Devereaux et al 2005) • Common manifestations. tachycardia • Mostly ST segment depression. sub-endocardial • About 50% due to coronary plaque rupture (Dawood et al. shortness of breath. 1996) • ST elevation MI uncommon..hypotension. arrhythmias.

Clin Geriatr Med 2008. 24:585-605) .When does perioperative MI occur? • • • • 44% on the day of surgery 34% on postoperative day 1 16% on postoperative day 2 94% have occurred by day 3 Troponin and ECG monitoring for three days after surgery required to detect many perioperative MIs (Mauck et al.

Surveillance for Perioperative MI Intraoperative and postoperative use of ST segment monitoring in known CAD or those undergoing vascular surgery. level B) Intraoperative and postop ST segment monitoring may be considered in patients with single or multiple risk factors for CAD undergoing non-cardiac surgery (Class IIb. Computerised ST segment monitoring preferred (Class IIa. Level B) (ACC/AHA 2007 guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery) .

Level C) • Not well established in clinically stable patients who have undergone vascular and intermediate risk surgery (IIb Level C) • Not recommended in asymptomatic stable patients undergoing low risk surgery ( III. Level C) .Surveillance for Perioperative MI • Postop Troponin recommended in patients with ECG changes or chest pain typical of ACS (Class 1.

Level C ESC 2009 guidelines) • More comprehensive evaluation compared to PAC • Role in at-risk patientss for non-cardiac surgery controversial . C) • Use of TEE to be considered in patients who develop STsegment changes on intraoperative or perioperative ECG monitoring (Class IIa .Surveillance for Perioperative MI Transesophageal Echocardiography • Acute and severe hemodynamic instability or lifethreatening abnormalities during or after surgery (I.

day1. 3 .ECG ECG monitoring with computerised ST analysis 12 lead ECG Comparison with preop ECG Repeating 12 lead ECG immediate postop. 2.

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SENTER S . and in V4 through V6 and I and aVL indicating lateral wall involvement (blue arrows). FRANCIS G S Cleveland Clinic Journal of Medicine 2009.Anterolateral ST-elevation MI with ST elevation in V1 through V3 indicating infarction of the anteroseptal myocardium (red arrows).76:159-166 ©2009 by Cleveland Clinic .

is therefore recommended” (Third Universal definition of MI.Expert Consensus document. both prior to and 48-72 h after major surgery. European Heart Journal (2012) 33 (2551-2567) .Serum Biomarkers • Serum troponin T / Troponin I assay • “Routine monitoring of cardiac biomarkers in high-risk patients.

European Heart Journal (2007) 28 2525-38 ) .(Universal definition of myocardial infarction.

Echocardiography Transthoracic echocardiography.to detect new regional wall motion abnormalities .

Management of Perioperative MI .

Initial Stabilisation • ABC.oxygen. nitrates.dobutamine. IV fluids • Inotropes if required.morphine for pain refractory to nitrates • Blood . dopamine • Anti-ischemic Therapy • Beta-blockers. calcium channel blockers if beta-blocker intolerant • Pain relief.

especially if EF is known to be low . glycoproteinIIb/IIIa inhibitors • Anticoagulation • Heparin. Fondaparinux • Statins • ACE.Initial Stabilisation • Antiplatelet agents • Aspirin. clopidogrel. LMWH.

Treatment and prevention of postoperative myocardial ischemia and MI.119:2936-2944 Copyright © American Heart Association . Landesberg G et al.Figure 5. Circulation 2009.

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Immediate PCI after Non-cardiac surgery • PCI requires antiplatelet cover • Risk of bleeding to be considered • May need to be cautious in case of surgery in closed spaces • Risk vs benefit assessment + team decision .

Conclusion In intermediate and high risk patients watch out for periop MI Perioperative MI a marker of future mortality Periop MI has 3 forms.symptomatic. upto 3 days postop to be considered in the at-risk Early detection and aggressive management key to successful outcome . asymptomatic. isolated enzyme release Preoperative and postoperative Troponin T .

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