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Perioperative Myocardial Infarction
In the elderly
Giora Landesberg MD, DSc, MBA
Associate Professor
Director, Cardiothoracic & Vascular
Anesthesia
Hadassah Medical Center
Jerusalem ISRAEL
3rd International Symposium: Perioperative Care for Seniors (2015)
The dominant paradigm:
Vulnerable plaque
Plaque rupture / erosion
Acute coronary syndrome
ST-elevation non-ST-elevation
3rd International Symposium: Perioperative Care for Seniors (2015)
ST
ST Necrosis by closed
Muscle
Necrosis by closed
Artery
Arrhythmias
CHF Death
CM Gibson 2002
non-ST-elevation versus ST-elevation MI
3rd International Symposium: Perioperative Care for Seniors (2015)
The majority of myocardial
infarctions occur in relatively
non-occluding coronary plaques
(<50% stenosis)
Falk E, Shah P & Fuster V. Circulation. 1995;92:657-671
3rd International Symposium: Perioperative Care for Seniors (2015)
Association of perioperative myocardial ischemia with cardiac morbidity and
mortality in men undergoing noncardiac surgery.
The study of Perioperative Ischemia Research Group
DT Mangano, WS Browner, M Hollenberg, MJ London, JF Tubau and IM Tateo
Perioperative ischemia is common (46%)
in high-risk patients undergoing major non-cardiac surgery
The majority of ischemic events are postoperative.
They are associated with postoperative cardiac
complications
The Holter monitoring era
New England J Medicine 1990;323:1781-8
3rd International Symposium: Perioperative Care for Seniors (2015)
Frank et al
J. Clin. Anesth. 1990;2:326-31.
PIRAT-I study
surgery
ST-trend
HR-trend
3rd International Symposium: Perioperative Care for Seniors (2015)
-6
-4
-2
0
2
4
6
5 10 15 20 25 30
-20
0
20
40
60
80
100
120
Time - (hours)
Heart
rate
- (
beats
/min
.)
HR and ST trends in a patient during CEA
ST-s
eg
men
t tren
d (m
m)
surgery
chest
pain
pulmonary
edema
ECG
64 yo lady
undergoes CEA
Background:
• IDDM
• TVD CAD
Perioperative Holter monitoring Prolonged postoperative ST-depression-type ischemia
CK-MB
elevation
3rd International Symposium: Perioperative Care for Seniors (2015)
% o
f p
ati
en
ts
151 major
vascular surgery
patients
Lancet 1993;341:715
3rd International Symposium: Perioperative Care for Seniors (2015)
3.9%
Most posto MI’s
are preceded by
prolonged ST-
depression, not
ST-elevation
Landesberg G.
Best practice and Research in
Anesthesiology 2005;19:77-95
1) Continuous on-line 12-lead ECG with
ST-segment monitoring (ST-Guard)
(starting before induction of anesthesia
until 2-3 days after surgery)
2) Cardiac troponins
(3 days postop.)
Mid 1990’s: Two new modalities
3rd International Symposium: Perioperative Care for Seniors (2015)
Β-blocker
PMH:
IHD, s/a CABG,
MI, reduced LVF
IDDM
HTN
PVD
s/a low-extremity bypass Sx.
MEDICATIONS:
atenolol, ACE-I, insulin,
aspirin
Case #1: 72 yo male
endarterectomyCarotid Surgery:
3rd International Symposium: Perioperative Care for Seniors (2015)
Prolonged postoperative
tachycardia-induced
ischemia on continuous
12-lead ECG
troponin elevation
Case #2 67 yo male
Surgery for Asymptomatic AAA (7.4 cm)
PMH:
• Hyperlipidemia, mild HTN, overweight
• quit smoking 12 yrs ago
• no history of IHD
• SOB on moderate exertion
Echocardiography
• LV & RV normal size and hyperfunction
• MV – moderate regurgitation
• Otherwise normal valves
3rd International Symposium: Perioperative Care for Seniors (2015)
LCX
LAD
RCA
Bisoprolol P.O.
for 1 month prior to the surgery
Surgery
Heart
rate
Surgery
Esmolol Heart
rate
Surgery
Esmolol
Prolonged
ischemia
Troponin-T
0.05
0.56
0.68
Prolonged postoperative tachycardia-induced ischemia on
continuous on-line 12-lead ECG
troponin elevation, but where is the plaque rupture?
Retrospective analysis of the
Cleveland Clinic registry:
1522 patients with preop. coronary angiography
21 hospital deaths or MI
42 matched controls
Am. J. Cardiology 1996
Duration of longest ST-depression type ischemia (min.)
r = 0.83
P = 0.0000
185 vascular
surgery patients
J. Am. Coll. Cardiol.
2001;37:1839-45
The major role of tachycardia
* * *
185 vascular
surgery patients
J. Am. Coll. Cardiol.
2001;37:1839-45
3rd International Symposium: Perioperative Care for Seniors (2015)
Onset of longest ischemia from the end of surgery (hrs)
1 0
8
6
4
2
0 0 5 10 15 20 25 30 35
All longest ischemic events
Events leading to myocardial infarction
Nu
mb
er
of
eve
nts
Timing of postoperative ischemia
185 vascular
surgery patients
J. Am. Coll. Cardiol.
2001;37:1839-45
Association with survival 447 major vascular
surgery patients
JACC 2003;42:1547-54
Troponin elevation after major vascular surgery is
common but is mostly silent !!
JACC 2003;42:1547-54
3rd International Symposium: Perioperative Care for Seniors (2015)
1,136 consecutive AAA patients
Abnormal cTnI concentrations were present in only 27% of all
patients with PMI at 6 h and in 93% by 48 h postoperatively.
Anesthesiology 2005;102:885-91
Coronary stenosis
70% 100% 50%
Plaque rupture – type MI
Prolonged, stress-induced ischemia – type MI
Inci
den
ce
J Cardiothoracic Vascular Anesthesia 2003;17:90-100
Universal definition of MI (Oct. 2007)
Circulation 2007;116:2634-53
Universal definition of MI (Oct. 2007)
Circulation 2007;116:2634-53
& prolonged tachycardia (increased heart rate) !!!
MI Myocardial
injury
Perioperative MI
is almost exclusively
type-II MI
Important definitions:
• Myocardial infarction – Rise and fall
of cTn >99th percentile in an ischemic
context (chest pain, ECG, etc.)
• Myocardial injury – Isolated cTn
elevation
Circulation 2009;119:2936-44
3rd International Symposium: Perioperative Care for Seniors (2015)
Prospective, multicenter (12 centers) 15,133 pts age ≥45, gen./reg. anesthesia cTnT measured at 6, 12hurs & pod 1,2,3 Outcome: 30 days mortality Peak TnT ≥ 0.02 ng/mL occurred in 11.6%
Can J Anesth 2012;59:1013-22
Without cTnI
With cTnI
Retrospective 2003-9, single center, Toronto
Of 51,701 pts 10,534 had cTnI measurements
Van Waes et al,
Circulation 2013
Single center cohort
2232 major nocardiac
surgery patients
Troponin-I on POD1-3,
19.4% had at least 1
troponin-I >0.06 ng/ml
Van Waes et al,
Circulation 2013
Single center cohort
2232 major nocardiac
surgery patients
Troponin-I on POD1-3,
19.4% had at least 1
troponin-I >0.06 ng/ml
Circulation,
Eur Heat J, 2012
JACC
Circulation 2009
;119:2936-44
Circulation 2009
;119:2936-44
Β-blocked
Not Β-blocked
Beattie et al.
Anesthesiology
2010;112:25-33
Retrospective analysis
of 4,387 noncardiac
surgery patients
Le Manach et al.
Anesthesiology
2012;117:1203-11
1,801 patients undergoing aortic
surgery