1. Perioperative Myocardial Infarctions The silent and neglected Killer
Kardiologie
Cardiovascular Research Institute Basel
Perioperative Myocardial Infarctions The silent and neglected Killer
Christian Puelacher, MD
diss:kurs
CRIB

2. Perioperative myocardial infarctions (PMI)
= heart attacks and injuries occuring during or after non-cardiac surgery ! ?
Def
Overlooked complication of major non-cardiac surgery, associated with significant risk of dying
Relevance of the perioperative setting PMI
What we know and what we dont know about PMI (the puzzle)
What is my research about
Christian Puelacher
diss:kurs 2

3. Guess the number of surgeries in:
900’000
>230 million
Make a guess, yes you guessed right, million surgeries per year (mostly in high-income countries), meaning ~ surgeries per year in Switzerland
Weiser, The Lancet 2008
Christian Puelacher
diss:kurs 3

4. * * * * * * What surgeries? * More common with increasing age
Schnell über Folie gehen, mehr blitzen
We have: Abdominal surgery (e.g. gall bladder removal), eye surgery (e.g. cataract), C-sections, orthopedic surgery (e.g. hips), Trauma surgery, Tumor surgery, Spinal surgery (e.g. disc surgery)
Increasingly common with age, meaning there are more surgeries in older patients. DEMOGRAPHIC change, Hence the «typical» surgery patient is changing, and with them the medical challenges. And one of these challenges are PMIs. *
* More common with increasing age
Christian Puelacher
diss:kurs 4

5. PMIs are challenging Difficult to diagnose because mostly silent 16%
The most prominent and known sign of spontaneous myocardial infarction is chest pain or other signs of dyscomfort. These are often blunted by perioperative analgesia. But also the mechanism might likely be different, not so much focussing on obstruction of a supplying heart vessel, but more diffuse problems of oxygen supply and demand by such factors as hypotension, potentially presenting with other unknown symptoms
Botto, Anaesthesiology 2013
Christian Puelacher
diss:kurs 5

6. PMI PMIs are challenging Associated with relevant mortality
Risk of death
Risk independent of symptoms
Days after surgery
Devereaux, JAMA 2012
Christian Puelacher
diss:kurs 6

7. ? ? ? O2 Knowledge gaps How to best diagnose PMI?
What is the pathophysiology of PMI?
Plaque rupture with thrombus ? O2
How to best diagnose an asymptomatic disease?
The heart is most commonly damaged by a lack of oxygen. Either by a blackage in an artery or...
What is the long-term prognosis?
Supply-demand imbalance O2
Christian Puelacher
diss:kurs 7

8. ?
My research
Basel Incidence, Patient Characteristics, Outcome and possible Strategies to improve Outcome of Perioperative Myocardial Injury after non-cardiac surgery: 1-Year Follow-up
PMI-Screening program for high-risk patients
Clinical observational trial
With so much things to learn I as PhD am quite happy and therefore we designed our study BASEL-PMI
Christian Puelacher
diss:kurs 8

9. BASEL-PMI Screening using cardiac blood marker Troponin ?
How to diagnose something asymptomatic:
In healthy myocardial cells there is a heart specific protein, troponin.
Healthy turnover
Christian Puelacher
diss:kurs 9

10. BASEL-PMI Study Flow Troponin measurment before surgery Surgery?
BASEL-PMI Study Flow
Troponin
measurment
before surgery
Surgery
Troponin
measurement
after surgery
Evaluation
in case of PMI
Christian Puelacher
diss:kurs 10

11. } { BASEL-PMI Study Flow x 2000 Work up of Clinical files Adjudication? } {
x 2000
BASEL-PMI Study Flow
Work up of
Clinical files
Adjudication
of event
1 year
contact
Datacleaning
Dataprocessing
Christian Puelacher
diss:kurs 11

12. T PMI D R Improve patient care Research and PhD aims reatment iagnosis?
Research and PhD aims
Better understand PMI T
reatment
PMI D
iagnosis R
isk
The aim of my study is to better understand PMI, to add an additional puzzle piece of knowledge to the picture of PMI and provide the basis for reliable diagnosis of PMI, but also lay the groundwork for future research aimed at better treatment and ideally risk prediction necessary to prevent PMIs from even happening.
With this I want to conclude my talk and hope I have given you a glimpse of what we do in clinical research.
Thank you for your attention and goodbye
Improve patient care
Christian Puelacher
diss:kurs 12