Archive for the ‘Perioperative MI’ Category

Yale Anesthesia Grand Rounds. Apr 28, 2017. Preop Cards Eval: Guidelines vs “Real World”

Wednesday, April 26th, 2017

2017_04_24 Ellis Preop Cardiac Evaluation

PGA NYC Dec 2015: Preoperative Cardiac Evaluation 2015: Guidelines vs “The Real World?”

Saturday, December 12th, 2015

2015_12_12 PGA NYC Ellis Preop Cardiac Evaluation .pptx_Page_01

2015_12_12 PGA NYC Ellis Preop Cardiac Evaluation .pptx

 

 

Update on Preop Cardiac Eval

Thursday, September 12th, 2013

Less emphasis on traditional CAD risk factors; more emphasis on CHR, arrhythmias, and frailty.

2012_11_24_-Ellis-Preop-Cardiac-Evaluation-1400-1530

destinationcme.com-wp-content-uploads-2013-07-2012_11_24_-Ellis-Preop-Cardiac-Evaluation-1400-1530

 

What are this month’s beta blocker guidelines?

Saturday, August 17th, 2013

I (Dr. Ellis) am Anesthesia Camp Course Director.  I gave Grand Rounds at NYU last month.

I talked about Perioperative Beta Blockade; click here for a PDF of the slides shown.

Your feedback, of course is appreciated.

Does your institution have automated reminders to continue perioperative beta blockade in paients taking them chronically?

bleeding bad 2013_07_27 NYU  John Ellis Beta blockade copy.pptx
Several new studies suggest that while beta blockade may protect in the absence of hemorrhage, it may harm when bleeding increases.

 

Hemorrhage increases periop Q wave MI and stroke following noncardiac surgery

Tuesday, July 10th, 2012

A new article in Circulation reviews hundreds of thousdands of patients in the NSQIP database.  They excluded cardiac, transplant, trauma, and neurosurgery patients. They find that approximately 1% of patients have >4 U RBC transfusion.  These patients have a 3-4 fold increase in rate of periop Q wave MI and/or stroke (approx 1% each).  No surprises there.  Patients undergoing vascular surgery were significantly over-represented in the hemorrhage category.

This retrospective study does not address the relationship of preexisting anticoagulant or antiplatelet drug use in these patients.  The reporting did not include routine ROMI (rule-out MI), suggesting under-reporting of PMI; we know that troponin increases, even in the absence of Q waves, are associated with poor long-term outcome after vascular surgery.

 

The authors and the editorial below discuss that perioperative strokes are usually ischemic, not hemorrhagic; and that hypotension is probably more important that anemia (low oxygen carrying capacity) perse in contributing to periop stroke.

In an accompanying editorial, Lee Goldman points out a number of limitations and suggestions for future research:

Most studies suggest a ~ 5:1 ratio of PMI:stroke, not the 1:1 ratio seen here.

In the Carson study, the ratio was 5.5 postoperative MIs for each postoperative stroke. So, NSQIP, which may well have missed some small postoperative strokes, undoubtedly missed 80% of postoperative MIs by modern diagnostic criteria. As a result, Kamel and colleagues clearly have substantially underestimated the absolute risk of postoperative MI attributable to perioperative hemorrhage and may also have substantially underestimated the relative risk resulting from postoperative hemorrhage.

He then goes on to criticize the present evidence base and guidelines for perioperative management of antiplatelet and anticoagulant therapy.

The American College of Chest Physicians publishes evidenced-based clinical practice guidelines for the perioperative management of antithrombotic therapy, the last of which was published in 2012.12 Although each iteration of these guidelines is logical and consensus-driven, each is based on weak data, essentially none from randomized trials…

As noted by Kamel and colleagues, this problem cries out for better data, which can be obtained only from placebo-controlled randomized trials. And the problem is getting even more important… we really do not know at all how best to manage these patients through noncardiac surgery…  It simply is not appropriate for us to keep tap dancing with recommendations whose scientific basis is no more sound than a variety of treatment guidelines…

He suggests three large RCTs to address the following questions:

  1. How best to manage patients who are on aggressive antiplatelet therapy after coronary stenting
  2. How best to manage patients who are treated long-term with aspirin or other antiplatelet agents for the secondary prevention of myocardial infarction or ischemic cerebrovascular events
  3. How best to manage patients who have atrial fibrillation and are receiving prophylactic anticoagulation to prevent embolic stroke.

 

Video: Aug 2011 lecture Periop Myocardial Ischemia and Infarction

Tuesday, August 23rd, 2011

Medical University of South Carolina Grand Rounds

Dr. John E. Ellis

Start watching video at 2:20

Periop MI continues to be lethal

Friday, July 22nd, 2011

Data from the POISE trial shows that periop MI continues to carry 10-15% lethality, and that symptomatic MI may have worse outcome than symptomatic ones.

Also note that medical Rx after MI remains suboptimal.  Our decision analysis years ago supports the routine use of troponin to screen patients after open AAA surgery.

A slide show of salient data follows below:

Surgery shortly after an MI still contraindicated?

Thursday, May 12th, 2011

An administrative database from the state of California suggests that surgery in the first month after an MI greatly increased the chances of reinfarction, and significantly increased the risk of death.  Vascular patients actually had lower RRs than other NCS, suggesting that the atherosclerotic burden is more uniformly increased in vascular patients compared to others (hips, colon resection), or that clinicians were more careful and/or attuned to caring for the vascular patients.

RESULTS: Postoperative MI rate for the recent MI cohort decreased substantially as the legth of time from MI to operation increased (0-30 days = 32.8%, 31-60 days = 18.7%, 61-90 days = 8.4%, and 91-180 days = 5.9%), as did 30-day mortality (0-30 days = 14.2%, 31-60 days = 11.5%, 61-90 days = 10.5%, and 91-180 days = 9.9%). MI within 30 days of an operation was associated with a higher risk of postoperative MI (RR range = 9.98-44.29 for the 5 procedures), 30-day mortality (RR range, 1.83-3.84), and 1-year mortality (RR range, 1.56-3.14).

CONCLUSIONS: A recent MI remains a significant risk factor for postoperative MI and mortality following surgery. Strategies such as delaying elective operations for at least 8 weeks and medical optimization should be considered

Many things have changed since Rao and El-Etr‘s classic paper:

  • TnI and CKMB are much more sensitive and more likely to be used as a screening tool than simply after symptoms occur.  Therefore, we suspect that the MIs detected in th 21st century may be smaller than in the past, but more prevalent.
  • PCI and more optimal medical Rx are available today, which might reduce the likelihood and lethality of reinfarction

The authors did not address the impact of medical Rx nor revascularization in this study.  However, the same group (least publishable units?) published another paper suggested that preop PCI or CABG protects against reinfarction.   They state:

Patients with a recent MI who were revascularized before surgery had an approximately 50% decreased rate of reinfarction (5.1% versus 10.0%; p < 0.001) and 30-day (5.2% versus 11.3%; p < 0.001) and 1-year mortality (18.3% versus 35.8%; p < 0.001) compared with those who were not. Stenting within 1 month of surgery was associated with a trend toward increased reinfarction (relative risk: 1.36; 95% CI, 0.96-1.97), and coronary artery bypass graft was associated with a decreased risk (relative risk: 0.70; 95% CI, 0.55-0.95).

Again, there are selection biases:

  • Emergent cases are probably too sick to wait for revascularization.
  • Some sick/frail patients may not be felt to be good candidates for revascularization.

In fact, only ~12% of revascularizations occurred in the 3 months before surgery.  At surgery < 1 month after original MI, reinfarction rates were high (~1/3) and no lower in the revascularization group.

For patients undergoing vascular surgery, early revascularization (within 1 month of MI) was associated with lower reinfarction rates compared with no revascularization (21.3% versus 34.2%; p = 0.026). In contrast, for those undergoing nonvascular surgery, reinfarction rates were greater for revascularized patients (40.4% versus 31.6%; p = 0.038). Patients undergoing vascular surgery were more likely to receive CABG than PTCA (53.7% versus 46.3%), but the reverse was true for nonvascular surgery (41.2% versus 58.8%) (p < 0.001). This pattern of revascularization was also seen for patients undergoing surgery within 1 month of MI (vascular: 43.8% CABG versus 56.3% PTCA; nonvascular: 32.9% CABG versus 67.1% PTCA; p = 0.10).

Lastly, the authors mention that the CARP trial did not show survival benefits for coronary revascularization before vascular surgery, but did suggest lower rates of MI after CABG than PCI, as these authors have also shown.

The debates continue!

MY SYLLABUS FOR 2010 AMERICAN SOCIETY OF ANESTHESIOLOGISTS REFRESHER COURSE

Sunday, June 20th, 2010

Ellis ASA Refresher Course Lecture 2010

Click above to download the syllabus

IS LEFT MAIN CORONARY STENTING PREFERABLE TO CABG?

Tuesday, June 8th, 2010

In “Case 2—2006Catastrophic Cardiovascular Collapse During Carotid Endarterectomy” JCTVA Volume 20Issue 2, Pages 259-268 (April 2006),” we suggested that PCI was becoming an option for left main CAD Rx, whereas traditional teaching had been that it should be treated with CABG.

In Circulation, published online, is support for this:

Outcomes in Patients With De Novo Left Main Disease Treated With Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) Trial @ http://goo.gl/UNAV

Patients with LM disease who had revascularization with PCI had safety and efficacy outcomes comparable to CABG at 1 year; longer follow-up is required to determine whether these 2 revascularization strategies offer comparable medium-term outcomes in this group of complex patients.

Of course, the case we commented upon (ACS during CEA with CPR) represented a true emergency.