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Raymond C. Roy, Ph.D., M.D. Professor & Chair of Anesthesiology Wake Forest University Baptist Medical Center Winston-Salem, North Carolina 27157-1009 rroy@wfubmc.edu
OVERVIEW
Discuss perioperative myocardial infarction Describe common event in PACU Discuss possible mechanisms
Myocardial ischemia vs infarction Myocardial stunning Myocardial reperfusion Other causes of anterior wall motion abnormality
Myocardial Infarction
Day of Surgery
Postop Day 2
Postop Day 4
PTCA to LAD
INFARCTION
OCCLUDING THROMBUS primary mechanism RUPTURE OF UNSTABLE PLAQUE ACUTE CORONARY SYNDROMES
MYOCARDIAL ISCHEMIA
Inadequate CBF
Short diastole (tachycardia) High LVEDP (hypertension, AS) LVH (subendocardial ischemia) Low CPP (diastolic BP < 60 mmHg) Reduced luminal diameter
Atherosclerotic plaque Coronary artery spasm Non-occluding thrombus
MYOCARDIAL INFARCTION
UNSTABLE CORONARY ARTERY PLAQUE PLAQUE RUPTURE THROMBUS FORMATION CORONARY ARTERY OCCLUSION
Lipid core
>40% plaque volume Extremely thrombogenic
-BLOCKERS BEST SUBGROUP IS THE ONE IN WHICH PATIENTS ARE TAKING STATINS
FEWER PLAQUE RUPTURES
ANTI-INFLAMMATORY EFFECT OF STATINS STATINS ACTUALLY HELP DISSOLVE LIPID CORE AND SHRINK PLAQUE SIZE.
COULD THIS MEAN T-WAVE INVERSION OCCURS BECAUSE OF A NATURAL REPERFUSION (CLOT DISSOLVES OR COLLATERAL FLOW ESTABLISHED)?
B-type natriuretic peptide - secreted by ventricles in response to increased enddiastolic pressure and volume expansion
Maisel. N Engl J Med 2002; 347:163
ECHOCARDIOGRAM anterior wall motion abnormal CORONARY ANGIOGRAPM 1/22 had lesion in LAD