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Myocardial Infarction and other Adverse events after Coronary Artery Bypass Surgery

Myocardial Infarction and other Adverse events after Coronary Artery Bypass Surgery. 4A Intern 梁耀龍 4A Intern 梁耀龍. Introduction. 800 000 patients undergo CABG surgery worldwide each year Arterial grafting, refinements in cardioplegia, minimally invasive surgery, OPCAB

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Myocardial Infarction and other Adverse events after Coronary Artery Bypass Surgery

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  1. Myocardial Infarction and other Adverse events after Coronary Artery Bypass Surgery 4A Intern 梁耀龍 4A Intern 梁耀龍

  2. Introduction • 800 000 patients undergo CABG surgery worldwide each year • Arterial grafting, refinements in cardioplegia, minimally invasive surgery, OPCAB • Patients undergoing CABG are now older and previous myocardial infarction (MI), stroke, or heart surgery • Morbidity and mortality after CABG surgery is expected to increase despite procedural advances.

  3. Adverse events in Coronary Artery Bypass Graft 1996 STS National Cardiac Surgery Database PATIENT POPULATION:170,895OPERATIVE SURVIVORS: 165,867 OPERATIVE MORTALITIES: 5,028 • Operative • Infection • Neurologic • Pulmonary • Renal • Valvular • Vascular • Other

  4. Operative

  5. Infection

  6. Neurologic

  7. Pulmonary

  8. Renal

  9. Valvular

  10. Vascular

  11. Others

  12. Adverse events in Coronary Artery Bypass Graft • 176 studies (205 717 patients) • AEs in-hospital or within 30 days after surgery death (2.1%) non-fatal MI (2.4%) non-fatal stroke (1.3%) gastrointestinal bleeding (1.5%) renal failure (0.8%) Adverse events in coronary artery bypass graft (CABG) trials: a systematic review and analysis.Heart 2003;89:767-772

  13. Non-fatal MI • Non-fatal MI occurred on average in 2.4% (median 2.4%, range 0–13.9%) of the overall CABG patients and was slightly lower in elective CABG than in mixed (2.3% v 2.6%). • Older age (> 60 years) and lower mean ejection fraction (50%) were not associated with a higher incidence of MI.

  14. Factors associated with increased 30 day mortality after CABG. • Age > 70 • Female sex • Low ejection fraction • History of stroke, MI, or heart surgery • Diabetes • Hypertension

  15. ACC/AHA Guidelines for CABGPerioperative Estimation of Risk of Mortality, Cerebrovascular Accident and Mediastinitis

  16. Perioperative Risk

  17. Calculation of Mortality Risk An 80-year-old female with an EF<40% who is having elective CABG surgery, has had no prior CABG surgery, and has no other risk factors. Her total score = 8 5(age>=80)+1.5(Female)+1.5(EF<40%) Predicted risk of Mortality = 3.9 %

  18. Out Comes of MI after CABG • 70~80% back to work by one year after surgery • By five years after CABG, • 15% anginal symptoms • 10% ischemic events • Postoperative MI have a risk of angina and ischemic events that is two to three times as high as that in patients who have not had such an infarction • By 10 years after surgery, patients who have received internal-thoracic-artery grafts have a mortality rate that is 10 percent lower than that among patients who have had saphenous-vein grafts Care after Coronary-Artery Bypass SurgeryNEJM. Volume 348:1456-1463,2003

  19. Management of MI (1) Stable angina • Drugs • Aspirin or clopidogrel • Beta-adrenergic antagonist • Calcium channel antagonist • Vasodilator-Nitrates • Lipid reduction-Satins • PTCA

  20. Management of MI (2)UA and non-ST elevation MI • Drugs • Aspirin and heparin • GP IIb/IIIa receptor antagonists • Antianginal therapy-ABCD • Morphine • Lipid-lowering therapy • IABP • PTCA

  21. Management of MI (3) ST elevation MI • Drugs • Aspirin and heparin • Beta-adrenergic antagonist • Nitroglycerin • Morphine • Oxygen • Glucose-insulin-potassium • Reperfusion therapy-Fibrinolytic therapy or primary PTCA within 12hr

  22. Factors reduce cardiovascular risk after CABG • Changes in Lifestyle • Smoking Cessation • Cardiac Rehabilitation • Psychosocial Management • Pharmacologic Interventions • Antiplatelet Drugs • Beta-Blockers and Angiotensin-Converting–Enzyme Inhibitors • Lipid-Lowering Agents • Control of Blood Pressure and Diabetes • Treatment of Depression

  23. Conclusion • Perioperative and post operative myocardial infarction is infrequent (2~5%) • Risk of mortality is lower than septicemia, permanent stroke, ventilation>1d, ARDS, RF, aortic dissection and valvular deterioration… • Incident is not associate with older age (> 60 years) and lower ejection fraction (50%) • Artery graft, changes in lifestyle and pharmacologic interventions can lower MI incident The End~ Thank you for attention

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