perioperative myocardial infarction (pmi)

Danielle Menosi Gualandro,MD,PhD [email protected]

Cardiology Department

Heart Institute, University of São Paulo Medical School

InCor - HCFMUSP

Perioperative Myocardial Infarction

mailto:[email protected]

Clinical case 1

JRS, 78y, male

Elective surgery AAA 6.0cm

No cardiac complaints

Medical history:

Hypertension

Former smoker

Medications:

Simvastatin 40mg

Enalapril 20mg

Main Lab results:

Hb 13.3

Cr 0.86mg/dL (76mmol/L)

ECG

Normal

PE:

BP 120x70mmHg HR 56

Clinical case 1

Elective operation: EVAR

Intraoperative: Surgery duration 130min BP 60-85 HR

50-60, no transfusion, efedrine 3x

No symptoms

Lowest hb 11.3g/dl, Creatinine normal, no infection

Preop PO6h 1PO 2PO 3PO

Hs-TnT (URL<14)

8 6 19 21 20

ECG normal normal - Lateral ST depression

Clinical case 1

a) Perioperative MI: dual antiplatelet therapy, heparin and coronary

angiography

b) Troponin elevation with no clinical meaning

c) Troponin elevation – higher risk of events, statins and ASA and

keep survillance in intermediate/intensive care unit, MPS before

hospital discharge

Clinical case 1 – coronary angiography

Case 2

• MR, 79a, w

• OP-Indikation: TEA femoral li

• Vorgeschichte: 3-Gefäss-KHK, PAVK IV, Z.n. 2x AMI, terminale Niereninsuffizienz, intermittierendes VHF

• Anamnese: Kann 1 Stockwerk hochsteigen, limitierend sind Beinschmerzen. gelegentlich retrosternale Schmerzen morgens, wenn sie sich zur Dialyse beeilen muss.

Verlauf

• Prä-OP hs-cTnT 141 ng/L

• OP-Verlauf unauffällig

• D1 hs-cTnT 135 ng/L

Verlauf

• Prä-OP hs-cTnT 141 ng/L

• OP-Verlauf unauffällig



– Patientin asymptomatisch

Prä-OP EKG

Post-OP EKG

Was würden Sie machen? 1) Koronarangiographie 2) Alles nur Typ II MI, 3) Myokardperfusionsszintigraphie

Keine Revaskularisation

PMI Pathophysiologie

• Type I versus Type II Myocardial Infarction

Gualandro D, et al. Atherosclerosis 2012, Thygesen K, et al. EHJ 2012

Hypotension

Anemia

Tachyarrhythmia

Noncardiac Surgery vs. Mortality

European Surgical Outcomes Study

7 days

498 hospitals

28 nations

46,539 patients

1,855 died in hospital (4%)

Mortality: 1.2% - 21.5%

UK (reference): 3.6%

Pearse et al. Lancet 2012;380:1059

Perioperative Myocardial Infarction (PMI)

300 millions surgeries/year

Incidence: 1 - 15%

High mortality (11-35%)

Hospital stay, cost

The Problem

Weiser et al. Lancet 2015; 385:S11

Perioperative Myocardial Infarction (PMI)

The Problem

Pubmed Publications Gualandro D Puelacher C Caramelli B

Plaque Rupture

Thrombosis

O2 supply/demand

imbalance

Hemodinamic Instability

Anemia

Pain

Presence of coronary obstructions

Platelet aggregation

Inflammatory response

HR and BP

Chatecolamines levels

Fibrinolysis

X

Pathophysiology

Type 1 MI Type 2 MI X


Fatal PMI

(n=42) Spontaneous

Fatal MI (n=25) P

Intra-plaque hemorrhage 19 (45%) 8 (32%) 0.32

Plaque rupture 3 (7%) 0 (0%) 0.29

Intraluminal thrombus

12 (28%) 9 (36%) 0.59

1 or more of above

23 (55%) 10 (40%) 0.31

Dawood M et al. Int J Cardiol 1996;57:37-44

Pathophysiology of Fatal PMI

Cohen MC, Aretz TH. Cardiovasc Pathol 1999;8:133-9

Plaque Rupture

(n=26)

46%

79.2%

56.7%

31.8%

p < 0.001

56.7%

45%

16.4%

Coronary Angiography

Gualandro DM et al. Atherosclerosis 2012; 222 (1):191-5.

N=120 N=120 N=240

Pathophysiology of PMI

Complex lesions

Ambose’s II lesions

SACS PACS Stable CAD

Clinical Features


Badner NH et al. Anesthesiology 1998;88:572-8 Ashton CM et al. Annals Inter Med 1993;118:504-10

Shah KB et al. Anesth Analg 1990;71:231-5

Devereaux et al. Ann Intern Med 2011;154:523-8

Gualandro DM et al. Atherosclerosis 2012; 22:191-5

72% Events in the first 72 hours

< 50% chest pain

Perioperative ACS

NSTEMI

STEMI

Unstable Angina

78.3%

15.8% 5.8%

PMI and type of Surgery

43.2%

20.1%

27.3%

9.4%

Devereaux PJ et al.

Annals Intern Med 2011;154;523-8

Gualandro DM et al.

Atherosclerosis 2012; 222 (1):191-5.

20.8%

38.3% 10%

8.3%

16.8% 5.8% Abdominal

Vascular

Urological

Orthopedic

Others

Head and Neck

Parashar A et al.

JACC 2016;68: 68:329-38

29.2%

13.9%

24.6%

14.2%

4.3% 8.6%

5.3%

281 Patients PCI

120 Patients coronary angiography

415 Patients PMI

Eletrocardiogram

Inespecific changes ST segment/T wave

Low specificity

Eletrolyte alterations, hypotermia, drugs

Echocardiogram

If normal, does not exclude MI

May help with differential diagnosis

Biomarkers = Troponin

Essential for diagnosis

Diagnostic Challenge


Evolutive Changes are essential

for diagnosis

↑ or ↓ of cardiac biomarkers values (troponin) with at

least 1 value above the 99th percentile AND

Symptoms of ischemia

New significant ST segment / T wave changes

New pathologic Q waves

Imaging evidence of new loss of viable myocardium or new

regional wall motion abnormality

Identification of an intracoronary thrombus by angiography or

autopsy

Thygesen K et al. Circulation 2012;126:2020-2035

PMI Diagnosis

Universal Definition of MI Criteria

Differential Diagnosis

Other Troponin elevation causes

Pulmonary Thromboembolism

Pericarditis

Acute heart failure

Arrhythmias

Myocarditis

Sepsis and septic shock

Shock

Acute renal failure

Roongsritong et al.Chest 2004;125;1877-1884

Differential Diagnosis

Isolated Troponin I Elevations

Vascular Surgery Meta-analysis

30-day Mortality: Negative Troponin = 2.3%

Isolated troponin elevation = 11.6%

Perioperative MI = 21.6%

P = 0.000001

Redfern et al. Anaesthesia 2011; 66: 604-10

VISION Study

15,133 Patients

Mortality 1.9%

Vision Study Investigators. JAMA 2012; 307:2295-2304

MINS (Myocardial Injury After Noncardiac Surgery)

VISION

15,065 patients

4th generation Troponin T > 0.04ng/ml + exclusion of other

causes of troponin elevations

1,200 (8%) Patients with MINS

Independent predictors of 30-day mortality in patients with

MINS

VISION Study Investigators. Anesthesiology 2014;120:564-78

OR IC P

Age > 75 years 2.06 1.33 - 3.37 0.003

ST elevation MI 3.96 3.96 – 1.54 0.005

Anterior wall ischemia in ECG 2.33 3.96 - 1.54 0.001

High-sensitivity troponin assays

in perioperative setting

0

10

20

30

40

50

60

70

Kavsak et al Alcock et al Nagele et al Gillmann etal

Weber et al Noordzij et al SP+ Basel Basel PMI

Preop

Postop

38

Perioperative hs-TnT

Gillmann et al. Crit Care Med 2014; 42:1498–1506.

Weber M et al. Eur Heart J 2013; 34:853–862.

Noordzij et al. British Journal of Anaesthesia 2015; 114: 909–18.

Kavsak et al. Clin Biochem 2011;44:1021-1024

Alcock et al. Heart 2012;44:1021-1024

Nagele et al. Am Heart J 2013; 166:325–332.

n=325 n=352 n=608 n=455 n=979 n=203

21

45

31

41

60

50

24

31

52

% > 14ng/L

28

65

n= 625/955

46

65

n=3106/1585

Basel PMI. Puelacher C et al. Preview

38

PMI: Diagnosis hs-TnT Troponin values > 99th percentile

Presence of noncardiac or

cardiac noncoronary cause?

MINS (Myocardial Injury After Noncardiac Surgery)

Third MI Universal Definition criteria present?

PMI

No

Yes

No

Yes Treatment

of cause

Chronic hs-TnT elevation?

No

No additional

measures

Yes

Foucrier A et al. Anesth Analg 2014; 119: 1053-63

PMI/MINS Treatment Elective infrarenal aortic surgery

Diagnosis PMI = DU OR contemporary Tn elevation

Foucrier A et al. Anesth Analg 2014; 119: 1053-63

PMI/MINS Treatment

Survival without experiencing major cardiac event (MI, myocardial

revascularization, pulmonary edema)

Limited evidence

Individual based approach

Multidisciplinary discussion

Ischemic Risk

Bleeding Risk

Treatment


1990 to 1998

MI until 7th postop day

Event-coronary angiography time = 4 hours

Berger PB et al. Am J Cardiol 2001;87:1100-102

48 patients

33 (68.8%)

STEMI

32 (66.7%)

Total coronary oclusion

Cardiac arrest

41 (85.4%)

PCI

12 (25%) 21 (43.7%)

Cardiogenic Shock

Mortality 35% 20% - RBC Transfusion 2% - Operative site bleeding

Perioperative MI Treatment

Perioperative MI Mortality

Parashar A et al. JACC 2016;68:329-38

25 (8.8%) patients were in shock

62 (22%) bleeding

45%STEMI patients received glycoprotein IIb/IIIa inhibitors

From 2003 to 2012

STEMI

PCI as soon as possible

No Fibrinolysis

Medications:

Adesanya AO et al. Chest 2006; 130:584-596

ASA

Clopidogrel

Statins

ACE inhibitors

Betablockers


Gualandro DM et al. Arq Bras Cardiol. 2011;96(3 Suppl 1):1-68

Non-ST Elevation MI

ASA

Clopidogrel

Heparin

Statins

ACE inhibitors

Betablockers

Hemodynamic instability, pain, anemia

Gualandro DM et al. Arq Bras Cardiol. 2011;96(3 Suppl 1):1-68


Treatment for O2 supply/demand imbalance

Treatment for plaque rupture

InCor-HCFMUSP

Coronary Angiography

PMI Mortality

Parashar A et al.

JACC 2016;68: 68:329-38

PMI = cTn > 5times URL

22% Bleeding

27% patients received glycoprotein

IIb/IIIa inhibitors

Mortality 11%

Patients submitted to PCI All Patients

PMI = Universal Definition

Mortality 15%

Bleeding: 9%

Devereaux et al.

Ann Intern Med

2011;154:523-8

Gualandro DM et al.

Atherosclerosis 2012;

22:191-5

Urgent coronary angiography

Left ventricule dysfunction / HF

Hemodynamic instability

Persistent Ischemia symptoms

Initial conservative (medical treatment)

Clear type II MI

Situations in which it is not possible to give antiplatelets and heparin

Adesanya AO et al. Chest 2006; 130:584-596

Age >75 years

Anterior wall ischemia in ECG

Non-ST Elevation MI


Gualandro DM et al. Arq Bras Cardiol 2011;96:1-68

Roffi M et al. Eur Heart J. 2016 Jan 14;37(3):267-315

Take home messages

Still high mortality rates

Pathophysiology: type I vs. Type II

Challenge for diagnosis

Surveillance is essential

All patients with intermediate and high cardiac risk estimated by the RCRI should be submitted to ECG + troponin daily for 3 days after surgery

Multidisciplinary discussion: bleeding risk vs ischemic risk


Thank you!


University of São Paulo

Medical School, Brasil Basel

perioperative myocardial infarction (pmi)

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