Risk For MI After Arthroplasty Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul...
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Transcript of Risk For MI After Arthroplasty Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul...
![Page 1: Risk For MI After Arthroplasty Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul Supervise by Assoc.Prof. Sirilak Suksompong.](https://reader035.fdocuments.us/reader035/viewer/2022070307/551a6ff0550346b52d8b4edf/html5/thumbnails/1.jpg)
Risk For MI After Arthroplasty
Present by R2 Choopong Luansritisakul R2 Jittrawan Attawattanakul
Supervise by Assoc.Prof. Sirilak Suksompong
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• 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
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Postoperative MI ?
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• 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.
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• 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.
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• LBBB
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• Postoperative Myocardial Infarction• Often recognized late (postoperative day 3
- 5), resulting in high (30% - 70%) mortality
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Morbidity and Mortality Incidence
From Anesthesiologist records in last year
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9 case
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Diagnosis Operation
Corneal ulcer with perforation LE
AMT patch with CT LE
Submandibular gland tumor Fibular free flap
BPH TUR-BT
AAA EVAR
ESRD AVF
Acute appendicitis Appendectomy
Perianal abscess I&D
CA larynx Total laryngectomy
SAH Craniotomy
Perioperative MI
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Myocardial InfarctionVS
Total Hip or Knee Replacement
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Study Year
No. of patien
ts
%Post-MI
F/U Design
Mantilla et al.
2002
10,244 0.4 30 d cohort
Gandhi et al.
2006
3,471 1.8 30 d retrospective
Parvizi et al.
2007
1,636 0.37 6 wk
cohort
Pulido et al.
2008
15,383 0.27 D/C cohort
Khatod et al.
2008
17,080 0.1 90 d retrospective
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• Limitation such as • small sample sizes• lack of matched control • only focused on short-term • no analysis for medication
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Strengths
• The nationwide population-based design• Large sample size• Information on matched controls• Completeness of follow-up
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• Nationwide matched control retrospective cohort study
• The Danish national registries
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Inclusion criteria
• Patients who underwent a primary THR or TKR surgery
• January,1998 to December, 2007• Age 18 years or older
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Exclusion criteria
• Prior AMI within 6 weeks before
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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
Thromboprophylaxis
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• Incidence of acute myocardial infarction• Potential risk factors
• Age • Sex • History of AMI, heart failure,
cerebrovascular disease • Drug dispensing within 6 months
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F/U time(yr) Male(%) Age,mean(yr)
IHD (%) CHF (%)0
10
20
30
40
50
60
70
80
3.9
36.9
71.9
12.57.9
4.1
36.9
71.9
10.56.5
Exposed(n=66,524) Unexposed(n=200,001)
Baseline Characteristics of patients Undergoing THR and Matched control
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NSAIDs B-Blockers Statins Antiplatelet0
10
20
30
40
50
6050.7
13.28.7
22.3
16.412.1
8.7
20.9
Exposed (n=66,524) unexposed (n=200,001)
Drug use within previous 6 mth (%)
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2 weeks
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6 weeks
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THR TKR0
5
10
15
20
25
30
2.41 2.26
12.4
9.2
25.3
11.2
18-59yr 60-79yr >80yr
Adjusted HR(6-wk risk for AMI)
Effect Modifiers of AMI risk after THR or TKR vs Matched controls
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Adjusted HR (6wk risk for AMI)
THR TKR
Previous MI 2.12 (1.59-2.83) 1.15 (0.55-2.42)
1.5-6 mo before
4.25 (2.24-8.05) 4.14 (0.91-18.87)
6-12 mo before 3.82 (1.90-7.67) 2.18 (0.28-16.79)
>12 mo before 1.91 (1.40-2.59) 0.96 (0.43-2.17)
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Adjusted HR (6wk risk for AMI)
THR TKR
NSAIDs 1.80 (1.31-2.47)
1.64 (0.78-3.42)
B-Blockers 1.45 (1.11-1.88)
1.49 (0.82-2.67)
Platelet inhibitors 1.33 (1.03-1.73)
2.30 (1.21-4.37)
Adjusted HR (6wk risk for AMI)
THR TKR
Heart failure 2.47 (1.90-3.20)
3.75 (2.01-6.98)
Cerebrovascular disease
2.06 (1.57-2.70)
2.09 (1.05-4.15)
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MarrowEmbolization
AntithromboticAgents
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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
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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
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• Increase risk of AMI during the first 2 weeks after arthroplasty
• AMI within 1 year should be contraindication for undergoing elective THR surgery
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• Prophylactic therapy• Adrenergic Blockers• Statins• Calcium channel Blockers• 2 Agonists• Aspirin
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• Prophylactic therapy• Adrenergic Blockers
• Long term should not be discontinued• No study has compared prophylactic B-
Blockade with short term
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• Prophylactic therapy• Adrenergic Blockers• Statins
• Abrupt withdrawal cause plaque destabilization
• Reduced perioperative and long term cardiac complication
• Large randomized controlled trials are still needed
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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
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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
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