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Risk For MI After Arthroplasty

Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul Supervise by Assoc.Prof . Sirilak Suksompong. Risk For MI After Arthroplasty. A 81 year-old man Admit for Elective total hip replacement Underlying disease : HT on Atenolol (50) 1x1

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Risk For MI After Arthroplasty

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  1. Present by R2 ChoopongLuansritisakul R2 JittrawanAttawattanakul Supervise by Assoc.Prof. SirilakSuksompong Risk For MI After Arthroplasty

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

  5. 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.

  6. LBBB

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

  8. Morbidity and Mortality Incidence From Anesthesiologist records in last year

  9. 9 case

  10. Perioperative MI

  11. Myocardial Infarction VS Total Hip or Knee Replacement

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

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

  14. Nationwide matched control retrospective cohort study • The Danish national registries

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

  16. Exclusion criteria • Prior AMI within 6 weeks before

  17. 95,664 Patients 437 patients excluded THR group (n=66,524) Control group (n=200,001) TKR group (n=28,703) Control group (n=86,164) Thromboprophylaxis Thromboprophylaxis • Followed up until - Death • Migration • Revision THR or TKR • End of study period • Acute myocardial infarction

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

  19. Baseline Characteristics of patients Undergoing THR and Matched control

  20. Drug use within previous 6 mth (%)

  21. 2 weeks

  22. 6 weeks

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

  24. Marrow Embolization Antithrombotic Agents

  25. 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

  26. 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

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

  28. Prophylactic therapy •  Adrenergic Blockers • Statins • Calcium channel Blockers • 2 Agonists • Aspirin

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

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

  31. 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

  32. 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

  33. THANK YOU

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