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First time myocardial infarction in a rheumatic patient after elective arthroplasty.

ABSTRACT: The management of perioperative cardiovascular risk in patients with rheumatoid arthritis (RA) is challenging due to the independent contribution to risk by high grade inflammatory mechanisms and the underestimation of risk by traditional cardiac risk factors alone. RA is associated with accelerated rates of subclinical atherosclerosis and markedly higher rates of both myocardial infarction and sudden cardiac death over non-RA controls. There is an absence of prospectively validated perioperative coronary heart disease (CHD) risk assessment tools for this unique patient population and available guidelines may fail to identify those patients most at risk. We examine a singular case of first time myocardial infarction after uncomplicated elective surgery in an adult RA patient with an unrevealing preoperative cardiac assessment. We also review the current literature for shared pathogenic mechanisms between systemic inflammation and atherosclerosis, discuss clinical and biologic markers such as C-reactive protein (CRP) in RA patients associated with heightened cardiac risk and discuss recommendations based on available evidence for cardiovascular risk management in this at risk cohort.

SUBMITTER: Calloway JJ

PROVIDER: S-EPMC3757475 | biostudies-literature | 2013 Jul

REPOSITORIES: biostudies-literature

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First time myocardial infarction in a rheumatic patient after elective arthroplasty.

Calloway James J JJ Goodman Susan M SM Hollomon Wesley W Russell Linda A LA Krauser Daniel D

HSS journal : the musculoskeletal journal of Hospital for Special Surgery 20130529 2

The management of perioperative cardiovascular risk in patients with rheumatoid arthritis (RA) is challenging due to the independent contribution to risk by high grade inflammatory mechanisms and the underestimation of risk by traditional cardiac risk factors alone. RA is associated with accelerated rates of subclinical atherosclerosis and markedly higher rates of both myocardial infarction and sudden cardiac death over non-RA controls. There is an absence of prospectively validated perioperativ ...[more]

PMID: 24426869

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Project description:AimsThe prognostic importance of cardiac procedural myocardial injury and myocardial infarction (MI) in chronic coronary syndrome (CCS) patients undergoing elective percutaneous coronary intervention (PCI) is still debated.Methods and resultsWe analysed individual data of 9081 patients undergoing elective PCI with normal pre-PCI baseline cardiac troponin (cTn) levels. Multivariate models evaluated the association between post-PCI elevations in cTn and 1-year mortality, while an interval analysis evaluated the impact of the size of the myocardial injury on mortality. Our analysis was performed in the overall population and also according to the type of cTn used [52.0% had high-sensitivity cTn (hs-cTn)]. Procedural myocardial injury, as defined by the Fourth Universal Definition of MI (UDMI) [post-PCI cTn elevation ≥1 × 99th percentile upper reference limit (URL)], occurred in 52.8% of patients and was not associated with 1-year mortality [adj odds ratio (OR), 1.35, 95% confidence interval (CI) (0.84-1.77), P = 0.21]. The association between post-PCI cTn elevation and 1-year mortality was significant starting ≥3 × 99th percentile URL. Major myocardial injury defined by post-PCI ≥5 × 99th percentile URL occurred in 18.2% of patients and was associated with a two-fold increase in the adjusted odds of 1-year mortality [2.29, 95% CI (1.32-3.97), P = 0.004]. In the subset of patients for whom periprocedural evidence of ischaemia was collected (n = 2316), Type 4a MI defined by the Fourth UDMI occurred in 12.7% of patients and was strongly associated with 1-year mortality [adj OR 3.21, 95% CI (1.42-7.27), P = 0.005]. We also present our results according to the type of troponin used (hs-cTn or conventional troponin).ConclusionOur analysis has demonstrated that in CCS patients with normal baseline cTn levels, the post-PCI cTn elevation of ≥5 × 99th percentile URL used to define Type 4a MI is associated with 1-year mortality and could be used to detect 'major' procedural myocardial injury in the absence of procedural complications or evidence of new myocardial ischaemia.

Project description:Background Patient-reported outcome measures (PROMs) are increasingly being used to assess the effectiveness of elective total knee arthroplasty (TKA). However, little is known about how PROMs scores change over time in these patients. The aim of this study was to identify the trajectories of quality of life and joint functioning, and their associated demographic and clinical features in patients undergoing elective TKA. Methods A prospective, cohort study was conducted, in which PROMs questionnaires (Euro Quality 5 Dimensions 3L, EQ-5D-3L, and Knee injury and Osteoarthritis Outcome Score Patient Satisfaction, KOOS-PS) were administered to patients at a single center undergoing elective TKA before surgery, and at 6 and 12 months after surgery. Latent class growth mixture models were used to analyze the patterns of change in PROMs scores over time. Multinomial logistic regression was used to investigate the association between patient characteristics and PROMs trajectories. Results A total of 564 patients were included in the study. The analysis highlighted differential patterns of improvement after TKA. Three distinct PROMs trajectories were identified for each PROMs questionnaire, with one trajectory indicating the most favorable outcome. Female gender appears to be associated with a presentation to surgery with worse perceived quality of life and joint function than males, but also more rapid improvement after surgery. Having an ASA score greater than 3 is instead associated with a worse functional recovery after TKA. Conclusion The results suggest three main PROMs trajectories in patients undergoing elective TKA. Most patients reported improved quality of life and joint functioning at 6 months, which then stabilized. However, other subgroups showed more varied trajectories. Further research is needed to confirm these findings and to explore the potential clinical implications of these results. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-023-06373-2.

Project description:Whole-genome gene expression analysis has been successfully utilized to diagnose, prognosticate, and identify potential therapeutic targets for cardiovascular disease. However, the utility of this approach to identify outcome-related genes and dysregulated pathways following first-time myocardial infarction (AMI) remains unknown and may offer a novel strategy to detect affected expressome networks that predict long-term outcome. Whole-genome microarray and targeted cytokine expression profiling on blood samples from normal cardiac function controls and first-time AMI patients within 48-hours post-MI revealed expected differential gene expression profiles enriched for inflammation and immune-response pathways in AMI patients. To determine molecular signatures at the time of AMI that could prognosticate long-term outcomes, transcriptional profiles from sub-groups of AMI patients with (n=5) or without (n=22) any recurrent events over an 18-month follow-up were compared. This analysis identified 559 differentially expressed genes. Bioinformatic analysis of this differential gene set for associated pathways revealed 1) increasing disease severity in AMI patients is associated with a decreased expression of the developmental epithelial-to-mesenchymal transition, and 2) modulation of cholesterol transport genes that include ABCA1, CETP, APOA1, and LDLR is associated with clinical outcome. In conclusion, differentially regulated genes and modulated pathways were identified that predicted recurrent cardiovascular outcomes in first-time AMI patients. This cell-based approach for risk stratification in AMI warrants a larger study to determine the role of metabolic remodeling and regenerative processes required for optimal outcomes. A validated transcriptome assay could represent a novel, non-invasive platform to anticipate modifiable pathways and therapeutic targets to optimize long-term outcome for AMI patients. The overall experimental design includes blood samples from 21 control and 31 myocardial infaction patient groups. Among the 31patients, 5 patients have recurrent events. Microarray were peformed on the blood samples and comparisons of control vs patient and patients with recurrent events vs patients without recurrent events were performed to identify differential genes related to disease or patients groups with recurrent events for the following bioinformatic analysis.

Dataset Information

First time myocardial infarction in a rheumatic patient after elective arthroplasty.

Publications

First time myocardial infarction in a rheumatic patient after elective arthroplasty.

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