Acute Coronary Syndrome in the Postoperative Period: Detection and Management

Dr Arun Kumar Consultant Cardiac Anesthesiologist Sheikh Khalifa Medical City Abu Dhabi

Objectives

Background Recent advances Definition of MI Pathophysiology of perioperative MI Implications of perioperative MI and troponin release Diagnosis Management Conclusion

Postoperative MI!!

Diagnosis- by ECG, Troponin Management Give Oxygen Call Cardiologist

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Background

Cardiac complications are the most common cause of postoperative morbidity and mortality in non-cardiac surgery 200 million non-cardiac surgeries annually worldwide 1 million die of perioperative MI within 30 days

Perioperative MI is associated with increased and and long term mortality

Incidence of Perioperative MI

Varies with Definition of MI used Patient risk Population studied

A 1995 review found a pooled average rate of 1.4% in unselected patients >40 yrs to 6.9% in those referred for thallium scan (Mangano, NEJM 1995; 333:1750) In POISE Trial of 8000 patients at increased cardiovascular risk incidence was 5.1% at 30 days (Devereaux et al. Lancet 2008; 371:1839) In CARP trial, perioperative MI defined by rise in cardiac Troponin I seen in 27% of 377 patients scheduled for vascular surgery (McFalls et al. Eur Heart J 2008; 29: 394)

Patient Related Risk- Revised Cardiac Risk Index

History of IHD (MI, stress test, current chest pain, q waves, nitrates) History of CCF (history, PND, S3 gallop, CXR) History of Cerebrovascular Disease (stroke / TIA) Use of insulin therapy Preop creatinine >175 micromol/L

( Lee et al.Circulation 1999; 100; 1043-1049)

Risk of major perioperative cardiac event*

No. of risk factors 0 1 2 3 Risk of event 0.4% 0.9% 7% 11%

*cardiac death, nonfatal MI, nonfatal cardiac arrest

Procedure Related Risk

What has changed?

Previously MI defined by WHO criteria, ECG criteria, cardiac enzymes (CK-MB) ECG criteria subtle, transient, CK- MB limited sensitivity, specificity Thus postop MI was recognised late (day 3-5) with resultant high mortality (30-70%) Cardiac Troponin Assays have revolutionised detection and diagnosis of perioperative MI

The Troponins

Contractile protein in cardiac muscle Myocyte damage releases cTn into serum Detectable increase in troponin indicative of cardiac injury

cTn has nearly absolute myocardial tissue specificity and

reflect even microscopic zones of myocardial injury

But all cTn rises are not due to ACS, troponin increase in
isolation cannot be used to diagnose MI
(Continuing Education in Anaesthesia, Critical Care & Pain Volume 8 (2) 2008 )

Troponins

2000 consensus panel on MI defined cut off values

99th centile value of a normal population A measure of analytical precision, with a coefficient of variation of <10%

Until 2006 no commercial assays were capable of

measuring troponin levels with this analytical precision

Now high sensitivity, 5th generation troponin assays

available Each lab has its own cut off values!!
& (Continuing Education in Anaesthesia, Critical Care Pain Volume 8 (2) 2008 )

Definition of MI
Detection of a rise and /or fall of cardiac biomarker values (preferably cardiac troponin)
with at least one value above the 99th percentile of the upper reference limit (URL) and with atleast one of the following: Symptoms of ischemia New or presumed new sig.ST-segment-T wave changes or new LBBB New pathological Q-waves Imaging evidence of new loss of viable myocardium or new RWMA Identification of intracoronary thrombus by angio or autopsy

(Third Universal definition of myocardial infarction. European Heart Journal (2012) 33, 2551-2567)

(Universal definition of myocardial infarction. European Heart Journal (2007) 28 2525-38 )

Pathophysiology of Perioperative MI

The Spectrum of Perioperative MI

Poldermans, D. et al. J Am Coll Cardiol 2008;51:1913-1924

Copyright 2008 American College of Cardiology Foundation. Restrictions may apply.

Figure 3. The probability of type 1 and 2 MI as a function of the severity of CAD. Adapted from Landesberg G. The pathophysiology of perioperative myocardial infarction: facts and perspectives.

Landesberg G et al. Circulation 2009;119:2936-2944

Copyright American Heart Association

Implications of Perioperative MI and Troponin Release

Figure 4. Long-term survival of patients after major vascular surgery divided according to their highest troponin elevation obtained in the first 3 after days.

Landesberg G et al. Circulation 2009;119:2936-2944

Copyright American Heart Association

To examine characteristics and short term outcome of perioperative MI A cohort study from POISE trial 8351 patients from POISE Trial 4 cardiac biomarkers or enzyme assays measured within 3 days of surgery MI defined according to 2007 guidelines

From: Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery: A Cohort Study
Ann Intern Med. 2011;154(8):523-528. doi:10.1059/0003-4819-154-8-201104190-00003

Figure Legend:
Defining Features of Perioperative MI

Date of download: 10/5/2012

Copyright The American College of Physicians. All rights reserved.

From: Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery: A Cohort Study
Ann Intern Med. 2011;154(8):523-528. doi:10.1059/0003-4819-154-8-201104190-00003

Date of download: 10/5/2012

Copyright The American College of Physicians. All rights reserved.

30 day mortality higher for patients who had an MI than those who did not; 12% vs. 2% 65% of patients who had an MI did not have ischaemic symptoms Mortality similar between symptomatic and asymptomatic 58.3% of patients who had an MI died within 48hrs Median time to death in isolated enzyme rise group was 8 days Isolated enzyme rise after non-cardiac surgery also a predictor of mortality

From: Characteristics and Short-Term Prognosis of Perioperative Myocardial Infarction in Patients Undergoing Noncardiac Surgery: A Cohort Study
Ann Intern Med. 2011;154(8):523-528. doi:10.1059/0003-4819-154-8-201104190-00003

Figure Legend:
Independent Predictors of Perioperative MI

Date of download: 10/5/2012

Copyright The American College of Physicians. All rights reserved.

Change in practice?

Highest risk for death after periop MI is in the first 48h Need for: Quick diagnosis Intense monitoring Appropriate treatment Secondary prophylaxis- aspirin, beta-blockers, statins, ACE

The Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) Study JAMA. 2012; 307(21):2295-22304

VISION Study

To determine relationship between the peak 4th generation troponinT measurement in the first 3 days after non-cardiac surgery and 30-day mortality A prospective, international cohort study from Aug 2007 to Jan 2011 >45 yrs., GA /RA, elective, urgent or emergency non-cardiac surgery requiring overnight stay 4th generation Troponin 6-12 h postop and on day 1 , 2 and 3 24 potential predictors of 30-day mortality recorded Primary outcome measure mortality at 30 days after surgery 15,133 patients enrolled

From: Association Between Postoperative Troponin Levels and 30-Day Mortality Among Patients Undergoing Noncardiac Surgery
JAMA. 2012;307(21):2295-2304. doi:10.1001/jama.2012.5502

Figure Legend:

Date of download: 10/5/2012

Copyright 2012 American Medical Association. All rights reserved.

VISION Findings
Peak TnT values after noncardiac surgery strongest predictor of 30 day mortality 41.8% of deaths explained by elevated TnT Absolute risk of 30-day mortality TnT <0.01ng/ml 1% 0.02 ng/ml 4% 0.03-0.29ng/ml- 9.3% > 0.30- 16.9% Median time to death from peak TnT value 0.02ng/ml 13.5 days 0.03 ng/ml- 9 days

VISION Study- Change in practice

Monitoring TnT values for first 3 days after non-cardiac surgery substantially improves 30-day mortality risk stratification ? Intervention for at risk patients in the form of aspirin, statins , rate control etc.

Diagnosis

Perioperative MI- all reasons for missing it !

Mostly 48-72 h after surgery Only about 14% of patients experience chest pain Only 53% have clinical sign /symptom (Devereaux et al 2005) Common manifestations- hypotension, shortness of breath,
arrhythmias, tachycardia

Mostly ST segment depression, sub-endocardial About 50% due to coronary plaque rupture (Dawood et al., 1996) ST elevation MI uncommon, only 12% (London et al,1988)

When does perioperative MI occur?

44% on the day of surgery 34% on postoperative day 1 16% on postoperative day 2 94% have occurred by day 3

Troponin and ECG monitoring for three days after surgery required to detect many perioperative MIs

(Mauck et al. Clin Geriatr Med 2008; 24:585-605)

Surveillance for Perioperative MI

Intraoperative and postoperative use of ST segment monitoring in known CAD or those undergoing vascular surgery. Computerised ST segment monitoring preferred (Class IIa, level B)

Intraoperative and postop ST segment monitoring may be considered in patients with single or multiple risk factors for CAD undergoing non-cardiac surgery (Class IIb, Level B)

(ACC/AHA 2007 guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery)

Surveillance for Perioperative MI

Postop Troponin recommended in patients with ECG

changes or chest pain typical of ACS (Class 1, Level C)

Not well established in clinically stable patients who

have undergone vascular and intermediate risk surgery (IIb Level C)

Not recommended in asymptomatic stable patients

undergoing low risk surgery ( III, Level C)

Surveillance for Perioperative MI

Transesophageal Echocardiography Acute and severe hemodynamic instability or lifethreatening abnormalities during or after surgery (I, C)

Use of TEE to be considered in patients who develop STsegment changes on intraoperative or perioperative ECG monitoring (Class IIa , Level C ESC 2009 guidelines)

More comprehensive evaluation compared to PAC Role in at-risk patientss for non-cardiac surgery
controversial

ECG

ECG monitoring with computerised ST analysis 12 lead ECG Comparison with preop ECG Repeating 12 lead ECG immediate postop, day1, 2, 3

Anterolateral ST-elevation MI with ST elevation in V1 through V3 indicating infarction of the anteroseptal myocardium (red arrows), and in V4 through V6 and I and aVL indicating lateral wall involvement (blue arrows).

SENTER S , FRANCIS G S Cleveland Clinic Journal of Medicine 2009;76:159-166

2009 by Cleveland Clinic

Serum Biomarkers

Serum troponin T / Troponin I assay Routine monitoring of cardiac biomarkers in high-risk

patients, both prior to and 48-72 h after major surgery, is therefore recommended (Third Universal definition of MI- Expert
Consensus document, European Heart Journal (2012) 33 (2551-2567)

(Universal definition of myocardial infarction. European Heart Journal (2007) 28 2525-38 )

Echocardiography

Transthoracic echocardiography- to detect new regional wall motion abnormalities

Management of Perioperative MI

Initial Stabilisation

ABC- oxygen, IV fluids Inotropes if required- dobutamine, dopamine Anti-ischemic Therapy Beta-blockers, nitrates, calcium channel blockers if
beta-blocker intolerant

Pain relief- morphine for pain refractory to nitrates Blood

Initial Stabilisation

Antiplatelet agents Aspirin, clopidogrel, glycoproteinIIb/IIIa inhibitors Anticoagulation Heparin, LMWH, Fondaparinux Statins ACE- especially if EF is known to be low

Figure 5. Treatment and prevention of postoperative myocardial ischemia and MI.

Landesberg G et al. Circulation 2009;119:2936-2944

Copyright American Heart Association

Immediate PCI after Non-cardiac surgery

PCI requires antiplatelet cover Risk of bleeding to be considered May need to be cautious in case of surgery in closed
spaces

Risk vs benefit assessment + team decision

Conclusion
In intermediate and high risk patients watch out for periop MI Perioperative MI a marker of future mortality Periop MI has 3 forms- symptomatic, asymptomatic, isolated enzyme release Preoperative and postoperative Troponin T , upto 3 days postop to be considered in the at-risk Early detection and aggressive management key to successful outcome

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