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Risk For MI After Arthroplasty Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul Supervise by Assoc.Prof. Sirilak Suksompong.

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Presentation on theme: "Risk For MI After Arthroplasty Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul Supervise by Assoc.Prof. Sirilak Suksompong."— Presentation transcript:

1 Risk For MI After Arthroplasty Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul Supervise by Assoc.Prof. Sirilak Suksompong

2 A 81 year-old man Admit for Elective total hip replacement Underlying disease : HT on Atenolol (50) 1x1 DLP on Simvastatin (20) 1x1 Old CVA 4year ago (full recovery) Previous MI 11 months ago Choice of anesthesia : GA with ETT Intraoperative : no complication POD 7 : typical angina, ECG CK-MB 2.7 (0-3ng/ml), Trop-T 1.78(0-0.2ng/ml) Imp NSTEMI

3 Postoperative MI ?

4

5 Acute Myocardial Infarction Definition Detection of  and/or  of cardiac biomarker values (preferably cardiac troponin) with > value above the 99 th percentile upper reference limit and with > one of the following : Circulation, published online August 24,2012;  2012 American Heart Association,Inc.

6 Symptoms of ischemia New or presumed new significant ST-T changes or new LBBB Development of pathological Q waves in ECG Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality Identification of an intracoronary thrombus by angiography or autopsy Circulation, published online August 24,2012;  2012 American Heart Association,Inc.

7 LBBB

8 Postoperative Myocardial Infarction Often recognized late (postoperative day 3 - 5), resulting in high (30% - 70%) mortality

9 Morbidity and Mortality Incidence From Anesthesiologist records in last year

10 9 case

11 DiagnosisOperation Corneal ulcer with perforation LEAMT patch with CT LE Submandibular gland tumorFibular free flap BPHTUR-BT AAAEVAR ESRDAVF Acute appendicitisAppendectomy Perianal abscessI&D CA larynxTotal laryngectomy SAHCraniotomy Perioperative MI

12 Myocardial Infarction Myocardial InfarctionVS Total Hip or Knee Replacement

13

14 Limitation such as small sample sizes lack of matched control only focused on short-term no analysis for medication

15

16 Strengths The nationwide population-based design Large sample size Information on matched controls Completeness of follow-up

17 Nationwide matched control retrospective cohort study The Danish national registries

18 Inclusion criteria Patients who underwent a primary THR or TKR surgery January,1998 to December, 2007 Age 18 years or older

19 Exclusion criteria Prior AMI within 6 weeks before

20 95,664 Patients THR group (n=66,524) TKR group (n=28,703) Control group (n=86,164) Control group (n=200,001) Followed up until- Death -Migration -Revision THR or TKR -End of study period -Acute myocardial infarction 437 patients excluded Thromboprophylaxis

21 Incidence of acute myocardial infarction Potential risk factors Age Sex History of AMI, heart failure, cerebrovascular disease Drug dispensing within 6 months

22 Baseline Characteristics of patients Undergoing THR and Matched control

23 Drug use within previous 6 mth (%)

24 2 weeks

25 6 weeks

26

27

28

29

30 Adjusted HR (6-wk risk for AMI) Effect Modifiers of AMI risk after THR or TKR vs Matched controls

31 Adjusted HR (6wk risk for AMI) THRTKR Previous MI2.12 (1.59-2.83)1.15 (0.55-2.42)  1.5-6 mo before4.25 (2.24-8.05)4.14 (0.91-18.87)  6-12 mo before3.82 (1.90-7.67)2.18 (0.28-16.79)  >12 mo before1.91 (1.40-2.59)0.96 (0.43-2.17)

32 Adjusted HR (6wk risk for AMI) THRTKR NSAIDs1.80 (1.31-2.47)1.64 (0.78-3.42) B-Blockers1.45 (1.11-1.88)1.49 (0.82-2.67) Platelet inhibitors1.33 (1.03-1.73)2.30 (1.21-4.37) Adjusted HR (6wk risk for AMI) THRTKR Heart failure2.47 (1.90-3.20)3.75 (2.01-6.98) Cerebrovascular disease2.06 (1.57-2.70)2.09 (1.05-4.15)

33 Marrow Embolization Antithrombotic Agents

34 Limitations Lack of information on other risk factors for AMI smoking, blood pressure, biochemical variables, and BMI No information on inpatient anticoagulant use No information about GA or RA

35 GA vs RA General anesthesia vs Regional anesthesia showed a trend toward only 1.4 fold increase risk of AMI Anesthesia for hip fracture surgery in adults (Review)  2004 The Cochrane Collaboration

36 Increase risk of AMI during the first 2 weeks after arthroplasty AMI within 1 year should be contraindication for undergoing elective THR surgery

37 Prophylactic therapy  Adrenergic Blockers Statins Calcium channel Blockers  2 Agonists Aspirin

38 Prophylactic therapy  Adrenergic Blockers Long term should not be discontinued No study has compared prophylactic B-Blockade with short term

39 Prophylactic therapy  Adrenergic Blockers Statins Abrupt withdrawal cause plaque destabilization Reduced perioperative and long term cardiac complication Large randomized controlled trials are still needed

40 Perioperative Management Correct tachycardia, hypertension, hypotension, and pain Tight hemodynamic monitoring Blood transfusion in patients with CAD and Hb<10 Coronary intervention and antithrombotic therapy

41 Take Home Messages New definition of AMI THR and TKR patients increased risk of AMI during the first 2 weeks after surgery Elective THR and TKR should be contraindicated in patients with previous MI in last 1 year before Management for decrease risk of postoperative MI are necessary

42 THANK YOU


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