Acute Coronary Syndrome in the Postoperative Period: Detection and Management

7/30/2019 Acute Coronary Syndrome in the Postoperative Period: Detection and Management

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Acute Coronary Syndrome in the

Postoperative Period: Detection andManagement

Dr Arun KumarConsultant Cardiac AnesthesiologistSheikh Khalifa Medical City

Abu Dhabi


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Objectives

Background Recent advances

Definition of MI Pathophysiology of perioperative MI Implications of perioperative MI and troponin release

Diagnosis Management Conclusion


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Postoperative MI!!

Diagnosis- by ECG, Troponin

Management- Give Oxygen Call Cardiologist

THANK YOU


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When you search for something

Have an idea

Where it is likely to be!

What it looks like!

What to do when you find it !


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Background

Cardiac complications are the most common cause ofpostoperative morbidity and mortality in non-cardiacsurgery

200 million non-cardiac surgeries annually worldwide

1 million die of perioperative MI within 30 days

Perioperative MI is associated with increased and andlong term mortality


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Incidence of Perioperative MI

Varies with Definition of MI used Patient risk Population studied

A 1995 review found a pooled average rate of 1.4% in unselectedpatients >40 yrs to 6.9% in those referred for thallium scan (Mangano,NEJM 1995; 333:1750)

In POISE Trial of 8000 patients at increased cardiovascular riskincidence was 5.1% at 30 days (Devereaux et al. Lancet 2008;

371:1839) In CARP trial, perioperative MI defined by rise in cardiac Troponin I

seen in 27% of 377 patients scheduled for vascular surgery (McFalls etal. Eur Heart J 2008; 29: 394)


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Patient Related Risk- Revised Cardiac Risk Index

History of IHD (MI, stress test, current chest pain, q waves, nitrates)

History of CCF (history, PND, S3 gallop, CXR)

History of Cerebrovascular Disease (stroke / TIA)

Use of insulin therapy

Preop creatinine >175 micromol/L

( Leeet al.Circulation 1999; 100; 1043-1049)


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Risk of major perioperative cardiac event*

No. of risk factors Risk of event

0 0.4%

1 0.9%2 7%

3 11%

*cardiac death, nonfatal MI, nonfatal cardiac arrest


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Procedure Related Risk


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What has changed?

Previously MI defined by WHO criteria, ECG criteria,cardiac enzymes (CK-MB)

ECG criteria subtle, transient, CK- MB limited sensitivity,specificity

Thus postop MI was recognised late (day 3-5) withresultant high mortality (30-70%)

Cardiac Troponin Assays have revolutionised detectionand diagnosis of perioperative MI


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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 andreflect even microscopic zones of myocardial injury

But all cTn rises are not due to ACS, troponin increase inisolation cannot be used to diagnose MI

(Continuing Education in Anaesthesia, Critical Care &

Pain Volume 8 (2) 2008 )


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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


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Definition of MI

Detection of a rise and /or fall of cardiac biomarker values (preferably cardiactroponin)

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.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. European Heart Journal (2012) 33, 2551-2567)


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

2525-38 )


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Pathophysiology of Perioperative MI


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Copyright 2008 American College of Cardiology Foundation. Restrictions may apply.

Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924

The Spectrum of Perioperative MI


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Figure 3. The probability of type 1 and 2 MI as a function of the severity of CAD. Adapted from

Landesberg G. The pathophysiology of perioperative myocardial infarction: facts and

perspectives.

Landesberg G et al. Circulation 2009;119:2936-2944

Copyright American Heart Association


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Implications of Perioperative MI and Troponin

Release


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Figure 4. Long-term survival of patients after major vascular surgery divided according to

their highest troponin elevation obtained in the first 3 after days.




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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


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Date of download:

10/5/2012

Copyright The American College of Physicians.

All rights reserved.

From: Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing

Noncardiac Surgery: A Cohort Study

Ann Intern Med. 2011;154(8):523-528. doi:10.1059/0003-4819-154-8-201104190-00003

Defining Features of Perioperative MI

Figure Legend:


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Date of download:

10/5/2012







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30 day mortality higher for patients who had an MI than thosewho did not; 12% vs. 2%

65% of patients who had an MI did not have ischaemic

symptoms

Mortality similar between symptomatic and asymptomatic

58.3% of patients who had an MI died within 48hrs

Median time to death in isolated enzyme rise group was 8 daysIsolated enzyme rise after non-cardiac surgery also a predictor ofmortality


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Date of download:

10/5/2012






Independent Predictors of Perioperative MI

Figure Legend:


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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- aspirin, beta-blockers,statins, ACE


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The Vascular Events in Noncardiac Surgery Patients

Cohort Evaluation (VISION) Study JAMA. 2012;307(21):2295-22304


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VISIONStudy

To determine relationship between the peak 4th generationtroponinT measurement in the first 3 days after non-cardiacsurgery and 30-day mortality

A prospective, international cohort study from Aug 2007 to Jan2011

>45 yrs., GA /RA, elective, urgent or emergency non-cardiacsurgery requiring overnight stay

4th generation Troponin 6-12 h postop and on day 1 , 2 and 3

24 potential predictors of 30-day mortality recorded Primary outcome measure mortality at 30 days after surgery 15,133 patients enrolled


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Date of download: 10/5/2012Copyright 2012 American Medical

Association. All rights reserved.

From: Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing

Noncardiac Surgery

JAMA. 2012;307(21):2295-2304. doi:10.1001/jama.2012.5502

Figure Legend:


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VISION Findings

Peak TnT values after noncardiac surgery strongest predictor of30 day mortality

41.8% of deaths explained by elevated TnT

Absolute risk of 30-day mortality

TnT 0.30- 16.9%

Median time to death from peak TnT value 0.02ng/ml 13.5 days

0.03 ng/ml- 9 days


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VISION Study- 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,statins , rate control etc.


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Diagnosis


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Perioperative MI- 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-hypotension, shortness of breath,

arrhythmias, tachycardia

Mostly ST segment depression, sub-endocardial About 50% due to coronary plaque rupture (Dawood et al., 1996) ST elevation MI uncommon, only 12% (London et al,1988)


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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 requiredto detect many perioperative MIs

(Mauck et al. Clin Geriatr Med 2008; 24:585-605)


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Surveillance for Perioperative MI

Intraoperative and postoperative use of ST segmentmonitoring in known CAD or those undergoing vascularsurgery. Computerised ST segment monitoring preferred(Class IIa, level B)

Intraoperative and postop ST segment monitoring may beconsidered in patients with single or multiple risk factors forCAD undergoing non-cardiac surgery (Class IIb, Level B)

(ACC/AHA 2007 guidelines on Perioperative CardiovascularEvaluation and Care for Noncardiac Surgery)


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Postop Troponin recommended in patients with ECGchanges or chest pain typical of ACS (Class 1, Level C)

Not well established in clinically stable patients whohave undergone vascular and intermediate risk surgery

(IIb Level C)

Not recommended in asymptomatic stable patientsundergoing low risk surgery ( III, Level C)


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Transesophageal Echocardiography

Acute and severe hemodynamic instability or life-threatening abnormalities during or after surgery (I, C)

Use of TEE to be considered in patients who develop ST-segment changes on intraoperative or perioperative ECGmonitoring (Class IIa , Level CESC 2009 guidelines)

More comprehensive evaluation compared to PAC Role in at-risk patientss for non-cardiac surgerycontroversial


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ECG

ECG monitoring with computerised ST analysis

12 lead ECG

Comparison with preop ECG

Repeating 12 lead ECG immediate postop, day1, 2, 3


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Anterolateral ST-elevation MI with ST elevation in V1 through V3 indicating infarction of the

anteroseptal myocardium (red arrows), and in V4 through V6 and I and aVL indicating lateral

wall involvement (blue arrows).

SENTER S , FRANCIS G S Cleveland Clinic Journal of

Medicine 2009;76:159-166

2009 by Cleveland Clinic


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Serum Biomarkers

Serum troponin T / Troponin I assay

Routine monitoring of cardiac biomarkers in high-riskpatients, both prior to and 48-72 h after major surgery,is therefore recommended (Third Universal definition of MI- ExpertConsensus document, European Heart Journal (2012) 33 (2551-2567)


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

)


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Echocardiography

Transthoracic echocardiography- to detect new regional

wall motion abnormalities


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Management of Perioperative MI


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Initial Stabilisation

ABC- oxygen, IV fluids Inotropes if required- dobutamine, dopamine

Anti-ischemic Therapy Beta-blockers, nitrates, calcium channel blockers if

beta-blocker intolerant

Pain relief- morphine for pain refractory to nitrates

Blood


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Initial Stabilisation

Antiplatelet agents Aspirin, clopidogrel, glycoproteinIIb/IIIa inhibitors

Anticoagulation Heparin, LMWH, Fondaparinux

Statins

ACE- especially if EF is known to be low


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Figure 5. Treatment and prevention of postoperative myocardial ischemia and MI.




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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 closedspaces

Riskvsbenefit assessment + team decision


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Conclusion

In intermediate and high risk patients watch out for periopMI

Perioperative MI a marker of future mortality

Periop MI has 3 forms- symptomatic, asymptomatic, isolated

enzyme releasePreoperative and postoperative Troponin T , upto 3 dayspostop to be considered in the at-risk

Early detection and aggressive management key to

successful outcome


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THANK YOU

Acute Coronary Syndrome in the Postoperative Period: Detection and Management

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