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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

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

  • 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


Risk for mi after arthroplasty

Morbidity and Mortality Incidence

From Anesthesiologist records in last year




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



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



Risk for mi after arthroplasty

Drug use within previous 6 Matched controlmth (%)


Risk for mi after arthroplasty

2 weeks Matched control


Risk for mi after arthroplasty

6 weeks Matched control


Risk for mi after arthroplasty

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

Adjusted HR

(6-wk risk for AMI)


Risk for mi after arthroplasty

Marrow Matched control

Embolization

Antithrombotic

Agents


Limitations
Limitations Matched control

  • 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 Matched controlvs 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


Risk for mi after arthroplasty

  • Prophylactic therapy Matched control

    •  Adrenergic Blockers

    • Statins

    • Calcium channel Blockers

    • 2 Agonists

    • Aspirin


Risk for mi after arthroplasty

  • Prophylactic therapy Matched control

    •  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 Matched control

    •  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 Matched control 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 Matched control

  • 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 Matched control


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