Review of a Large Clinical Series: Perioperative Myocardial Infarction in Low-Risk Patients Undergoing Noncardiac Surgery Is Associated With Intraoperative Hypotension

Background: Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE). Methods: This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ⩽ 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death. Results: A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group ( p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group ( p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk ( p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%). Conclusions: In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.

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901-1 A Prospective, Randomized Trial Evaluating Early Discharge (Day 3) without Non-invasive Risk Stratification in Low Risk Patients with Acute Myocardial Infarction: PAMI-2

Journal of the American College of Cardiology ◽

10.1016/0735-1097(95)91478-g ◽

1995 ◽

Vol 25 (2) ◽

pp. 5A ◽

Cited By ~ 14

Author(s):

Bruce Brodie ◽

Cindy L. Grines ◽

Michael Spain ◽

John Griffin ◽

Carlos Balestrini ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Risk Stratification ◽

Randomized Trial ◽

Early Discharge ◽

Low Risk ◽

Prospective Randomized Trial ◽

Non Invasive ◽

Risk Patients

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P3609Temporal trends of the management and outcomes of patients after myocardial infarction according to the risk for recurrent cardiovascular events

European Heart Journal ◽

10.1093/eurheartj/ehz745.0468 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

T Grinberg ◽

T Bental ◽

Y Hammer ◽

A R Assali ◽

H Vaknin-Assa ◽

...

Keyword(s):

Myocardial Infarction ◽

High Risk ◽

Cardiovascular Events ◽

Risk Group ◽

Temporal Trends ◽

High Risk Group ◽

Low Risk ◽

Intermediate Risk ◽

High Risk Patients ◽

Risk Patients

Abstract Background Following Myocardial Infarction (MI), patients are at increased risk for recurrent cardiovascular events, particularly during the immediate period. Yet some patients are at higher risk than others, owing to their clinical characteristics and comorbidities, these high-risk patients are less often treated with guideline-recommended therapies. Aim To examine temporal trends in treatment and outcomes of patients with MI according to the TIMI risk score for secondary prevention (TRS2°P), a recently validated risk stratification tool. Methods A retrospective cohort study of patients with an acute MI, who underwent percutaneous coronary intervention and were discharged alive between 2004–2016. Temporal trends were examined in the early (2004–2010) and late (2011–2016) time-periods. Patients were stratified by the TRS2°P to a low (≤1), intermediate (2) or high-risk group (≥3). Clinical outcomes included 30-day MACE (death, MI, target vessel revascularization, coronary artery bypass grafting, unstable angina or stroke) and 1-year mortality. Results Among 4921 patients, 31% were low-risk, 27% intermediate-risk and 42% high-risk. Compared to low and intermediate-risk patients, high-risk patients were older, more commonly female, and had more comorbidities such as hypertension, diabetes, peripheral vascular disease, and chronic kidney disease. They presented more often with non ST elevation MI and 3-vessel disease. High-risk patients were less likely to receive drug eluting stents and potent anti-platelet drugs, among other guideline-recommended therapies. Evidently, they experienced higher 30-day MACE (8.1% vs. 3.9% and 2.1% in intermediate and low-risk, respectively, P<0.001) and 1-year mortality (10.4% vs. 3.9% and 1.1% in intermediate and low-risk, respectively, P<0.001). During time, comparing the early to the late-period, the use of potent antiplatelets and statins increased among the entire cohort (P<0.001). However, only the high-risk group demonstrated a significantly lower 30-day MACE (P=0.001). During time, there were no differences in 1-year mortality rate among all risk categories. Temporal trends in 30-day MACE by TRS2°P Conclusion Despite a better application of guideline-recommended therapies, high-risk patients after MI are still relatively undertreated. Nevertheless, they demonstrated the most notable improvement in outcomes over time.

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Utilization of an ICU Severity of Illness Scoring System to Triage Patients With ST-Elevation Myocardial Infarction

Journal of Intensive Care Medicine ◽

10.1177/0885066620928263 ◽

2020 ◽

pp. 088506662092826

Author(s):

Jonathan M. Norton ◽

Prathibha K. Reddy ◽

Keshab Subedi ◽

Carly A. Fabrizio ◽

Neil J. Wimmer ◽

...

Keyword(s):

Myocardial Infarction ◽

High Risk ◽

Scoring System ◽

Intermediate Level ◽

Low Risk ◽

St Elevation Myocardial Infarction ◽

Level Of Care ◽

Apache Iii ◽

Risk Patients ◽

St Elevation

Objective: To subjectively identify low-risk ST-elevation myocardial infarction (STEMI) patients and triage this low-risk population to an intermediate level of care. Background: Many patients with STEMI are admitted to the intensive care unit (ICU), however, a large portion do not merit ICU admission. We sought to examine whether, among post-STEMI patients admitted to the ICU, if an easily obtainable subjective scoring system could predict low-risk patients and safely triage them to an intermediate level of care. Methods: Retrospective observational study at Christiana Hospital, a 900-bed regional referral center. Data were defined by the ACTION Registry and CathPCI Registry. Acute Physiology and Chronic Health Evaluation (APACHE) predictions were retrieved for all patients with STEMI and were analyzed for complications, length of stay, and inhospital mortality. We then examined subjective criteria to triage patients with STEMI out of the ICU. Results: Among 253 patients with STEMI, 179 (70.75%) were classified as low risk (intermediate level care appropriate) and 74 (29.25%) were classified as high risk (ICU appropriate). The mean age was 64.95 years. The APACHE III score was right skewed with a mean of 36.97 and a median of 31. There was a significant difference between the APACHE III score of low-risk patients and the APACHE III score of high-risk patients (P < .001). Conclusion: In conclusion, patients characterized as low risk, as defined by our criteria, had low APACHE III scores and a low likelihood of complications post-STEMI. This low-risk population could potentially be admitted to an intermediate level of care, avoiding the ICU altogether.

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PERIOPERACINIS MIOKARDO INFARKTAS

Sveikatos mokslai ◽

10.5200/sm-hs.2013.129 ◽

2013 ◽

Vol 23 (6) ◽

pp. 29-34

Author(s):

Andrius Macas ◽

Giedrė Bakšytė ◽

Laura Šilinskytė ◽

Jūratė Petrauskaitė

Keyword(s):

Myocardial Infarction ◽

Cardiac Surgery ◽

Oxygen Supply ◽

Plaque Rupture ◽

Perioperative Period ◽

Vascular Complication ◽

Early Postoperative Period ◽

Hospital Length Of Stay ◽

Perioperative Myocardial Infarction ◽

Risk Patients

Perioperative myocardial infarction (PMI) is defined as myocardial infarction (MI) during perioperative period (24-72 hours after non cardiac surgery). Worldwide, over 200 million adults have major non-cardiac surgery each year, and several million experience a major vascular complication (e.g.: nonfatal myocardial infarction). The prevalence of PMI for low risk patients without ischemic heart disease is from 0.3 to 3%, while for medium and high risk patients with coronary artery disease increases to 30%. It is believed that plaque rupture and myocardial oxygen supply-demand imbalance is the main reason of perioperative myocardial infarction. Mostly oxygen supply-demand imbalance predominates in the early postoperative period. Plaque rupture appears to be a more random event, distributed over the entire perioperative admission. Most patients with a perioperative MI do not experience ischemic symptoms, because of sedation and analgesia during surgery procedure. This is the reason why routine monitoring of troponin levels and electrocardiography in at-risk patients are needed after surgery to detect most MI. In 90% of cases troponin level inceases during the first 24 hours after surgery. Risk factors detection, serial troponin evaluation and specialised treatment can reduce hospital length of stay, treatment costs and PMI mortality.

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