Risk for mi after arthroplasty
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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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Risk for mi after arthroplasty

Present by R2 ChoopongLuansritisakul

R2 JittrawanAttawattanakul

Supervise by Assoc.Prof. SirilakSuksompong

Risk For MI After Arthroplasty


Risk for mi after arthroplasty

  • 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


Risk for mi after arthroplasty

Postoperative MI ?


Risk for mi after arthroplasty

  • 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.


Risk for mi after arthroplasty

  • 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.


Risk for mi after arthroplasty

  • LBBB


Risk for mi after arthroplasty

  • Postoperative Myocardial Infarction

    • Often recognized late (postoperative day 3 - 5), resulting in high (30% - 70%) mortality


Risk for mi after arthroplasty

Morbidity and Mortality Incidence

From Anesthesiologist records in last year


Risk for mi after arthroplasty

9 case


Risk for mi after arthroplasty

Perioperative MI


Risk for mi after arthroplasty

Myocardial Infarction

VS

Total Hip or Knee Replacement


Risk for mi after arthroplasty

  • Limitation such as

    • small sample sizes

    • lack of matched control

    • only focused on short-term

    • no analysis for medication


Strengths

Strengths

  • The nationwide population-based design

  • Large sample size

  • Information on matched controls

  • Completeness of follow-up


Risk for mi after arthroplasty

  • Nationwide matched control retrospective cohort study

  • The Danish national registries


Inclusion criteria

Inclusion criteria

  • Patients who underwent a primary THR or TKR surgery

  • January,1998 to December, 2007

  • Age 18 years or older


Exclusion criteria

Exclusion criteria

  • Prior AMI within 6 weeks before


Risk for mi after arthroplasty

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


Risk for mi after arthroplasty

  • Incidence of acute myocardial infarction

  • Potential risk factors

    • Age

    • Sex

    • History of AMI, heart failure, cerebrovascular disease

    • Drug dispensing within 6 months


Risk for mi after arthroplasty

Baseline Characteristics of patients Undergoing THR and Matched control


Risk for mi after arthroplasty

Drug use within previous 6 mth (%)


Risk for mi after arthroplasty

2 weeks


Risk for mi after arthroplasty

6 weeks


Risk for mi after arthroplasty

Effect Modifiers of AMI risk after THR or TKR vs Matched controls

Adjusted HR

(6-wk risk for AMI)


Risk for mi after arthroplasty

Marrow

Embolization

Antithrombotic

Agents


Limitations

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


Ga vs ra

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


Risk for mi after arthroplasty

  • Increase risk of AMI during the first 2 weeks after arthroplasty

  • AMI within 1 year should be contraindication for undergoing elective THR surgery


Risk for mi after arthroplasty

  • Prophylactic therapy

    •  Adrenergic Blockers

    • Statins

    • Calcium channel Blockers

    • 2 Agonists

    • Aspirin


Risk for mi after arthroplasty

  • Prophylactic therapy

    •  Adrenergic Blockers

      • Long term should not be discontinued

      • No study has compared prophylactic B-Blockade with short term


Risk for mi after arthroplasty

  • Prophylactic therapy

    •  Adrenergic Blockers

    • Statins

      • Abrupt withdrawal cause plaque destabilization

      • Reduced perioperative and long term cardiac complication

      • Large randomized controlled trials are still needed


Risk for mi after arthroplasty

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


Risk for mi after arthroplasty

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


Thank you

THANK YOU


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