A large study reports a high increased risk for acute MI (AMI) in the first 6 weeks after total-hip replacement (THR) or total-knee replacement (TKR) surgery. Analyzing a nationwide cohort from Denmark that included 95,227 patients who underwent THR or TKR and matched controls, Arief Lalmohamed and colleagues calculated the adjusted hazard ratios (HR) for AMI. Their results are published in the Archives of Internal Medicine.
The risk for AMI was significantly higher in the first two postoperative weeks for both THR and TKR, but the risk was higher only in the THR group for weeks 2 through 6.
Adjusted HR, Weeks 1 to 2:
- THR: 25.5 (95% CI, 17.1-37.9)
- TKR: 30.9 (95% CI, 11.1-85.5)
Adjusted HR, Weeks 2 to 6:
- THR: 5.05 (95% CI, 3.58-7.13)
- TKR: 0.81 (95% CI, 0.37-1.77)
At 6 weeks, the absolute rate of AMI was 0.51% in the THR group and 0.21% in the TKR group. The only significant effect modifier identified by the investigators was age, with the greatest excess risk found in patients age 80 or older. By contrast, no increase in risk was found in patients younger than 60 years.
In an accompanying commentary, Arthur Wallace writes that the study “once again confirms that the perioperative period increases cardiac risk. Physicians must go further than establishing risk factors; physicians must actively work to reduce perioperative risk.” Risk can be reduced with the appropriate use of preoperative beta-blockers, clonidine, statins, and aspirin, he writes. Despite level 1 evidence supporting the use of antiischemic agents, many physicians discontinue their use in the perioperative period, he notes.
Here is the press release from Archives:
Increased Heart Attack Risk Associated with Total Hip, Knee Replacement Surgeries
CHICAGO – Total hip replacement (THR) and total knee replacement (TKR) surgeries were associated with increased risk of acute myocardial infarction (AMI, heart attack) in the first two weeks after the surgical procedures, according to report published Online First by Archives of Internal Medicine, a JAMA Network publication.
THR and TKR are effective for treating patients with moderate to severe osteoarthritis. These surgical procedures are commonly performed, with an estimated 1.8 million procedures performed annually worldwide, according to the study background.
“This study demonstrated an increased risk of AMI during the first two weeks after THR (25-fold) and TKR (31-fold) surgery compared with matched controls. The risk of AMI sharply decreased after this period, although it remained significantly elevated in the first six weeks for THR patients. The association was strongest in patients 80 years or older, whereas we could not detect a significantly increased risk in patients younger than 60 years,” Arief Lalmohamed, Pharm.D., of Utrecht University, the Netherlands, and colleagues comment.
Researchers utilized Danish national registries for their study that enrolled patients who underwent THR or TKR (n=95,227) from January 1998 through December 2007 and 286,165 individuals as matched controls. The mean (average) age for THR patients was just less than 72 years and for TKR patients it was just more than 67 years.
The absolute six-week risk of AMI was 0.51 percent in THR patients and 0.21 percent in TKR patients, according to the results.
“Furthermore, a previous AMI in the six months before surgery increased the risk of new AMI during the first six weeks after THR and TKR (4-fold increase) surgery but did not modify the relationship between THR or TKR and AMI,” the authors conclude.
(Arch Intern Med. Published online July 23, 2012. doi:10.1001/archinternmed.2012.2713)
Editor’s Note: The Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences has received unrestricted funding for pharmacoepidemiologic research from GlaxoSmithKline, the private-public-funded Top Institute Pharma, the Dutch Medicines Evaluation Board and the Dutch Ministry of Health. This study was supported by a grant from the Netherlands Organization for Scientific Research. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
Commentary: Important for Physicians to Recognize, Reduce Cardiac Risk
In a commentary, Arthur W. Wallace, M.D., Ph.D., of the University of California, San Francisco, writes: “The perioperative period is stressful to patients … The present study once again confirms that the perioperative period increases cardiac risk. Physicians must go further than establishing risk factors; physicians must actively work to reduce perioperative risk.”
“It is important for physicians caring for patients in the perioperative period to recognize the potential for cardiac morbidity and mortality and then appropriately use the armamentarium of medical therapies we now have to reduce cardiac risk, prevent perioperative MIs (myocardial infarction, heart attack), and prevent cardiac deaths,” Wallace continues.
“In their present study, Lalmohamed et al clearly reinforce the importance and significance of the cardiac risk and the need to prevent perioperative cardiac morbidity and mortality,” Wallace concludes.
(Arch Intern Med. Published online July 23, 2012. doi:10.1001/archinternmed.2012.3776)
Editor’s Note: This work has been supported by the Northern California Institute for Research and Education and the Veterans Affairs Medical Center, San Francisco. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
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