What is the management for ST elevation after heart surgery?

Management of ST Elevation After Heart Surgery

Patients with ST elevation after heart surgery should undergo urgent evaluation with escalation of medical therapy (nitrates and beta-blockers), initiation of intravenous anticoagulation, and urgent cardiac catheterization if hemodynamically unstable or with evidence of large area of myocardium at risk. 1

Initial Assessment and Management

• ST elevation following cardiac surgery requires immediate attention as it may represent true myocardial ischemia despite being commonly considered non-specific post-operatively 2
• Initial management should include:
  • Escalation of medical therapy with nitrates and beta-blockers to decrease myocardial oxygen demand and reduce ischemia 1
  • Initiation of intravenous anticoagulation if not already accomplished 1
  • Continuous cardiac monitoring and serial ECGs to track changes 1

Urgent Intervention Criteria

• Patients with any of the following should be referred urgently for cardiac catheterization:
  • Hemodynamic instability
  • Poor left ventricular function
  • Large area of myocardium at risk 1
• Insertion of an intra-aortic balloon pump should be considered in these high-risk patients 1
• Coronary angiography and PCI should ideally be performed within 60 minutes from the onset of recurrent discomfort in high surgical risk patients 1

Revascularization Strategy

• Patients who are candidates for revascularization should undergo coronary arteriography and PCI or CABG as dictated by coronary anatomy 1
• For patients with failed PCI and persistent pain or hemodynamic instability, emergency CABG should be undertaken if coronary anatomy is suitable 1
• For patients with persistent or recurrent ischemia refractory to medical therapy, CABG should be performed if they have suitable coronary anatomy and significant area of myocardium at risk 1

Special Considerations After Heart Surgery

• Consider potential causes specific to post-cardiac surgery setting:
  • Graft occlusion requiring urgent intervention 2
  • External compression of coronary arteries by mediastinal drains or tubes 3
  • Non-ischemic causes such as pericarditis or normal post-surgical changes 4
• In patients with ST elevation but without evidence of perioperative MI (no new Q waves and normal cardiac enzymes), ST elevation may not be associated with increased morbidity or mortality 4

Pharmacological Management

• Antiplatelet therapy:
  • Aspirin should not be withheld before urgent CABG 1
  • For patients already on dual antiplatelet therapy requiring surgery, clopidogrel or ticagrelor should be discontinued at least 24 hours before urgent on-pump CABG if possible 1
• For recurrent ST elevation and ischemic chest discomfort in patients not suitable for revascularization, readministration of fibrinolytic therapy may be reasonable 1
• Standard post-MI medical therapy should be prescribed as defined in the ACC/AHA Guidelines for STEMI management 1

Long-term Management

• Patients who sustain a perioperative MI should have:
  • Evaluation of left ventricular function before hospital discharge 1
  • Risk stratification with exercise testing or pharmacological stress testing 1
  • Management of cardiovascular risk factors (hypertension, hyperlipidemia, diabetes mellitus) 1
  • Standard post-infarction medical therapy including aspirin, beta-blockers, and ACE inhibitors 1

Monitoring and Follow-up

• Continuous cardiac monitoring during the early post-operative period 2
• Serial ECGs and cardiac biomarkers to detect evolving myocardial injury 1
• Echocardiography to assess ventricular function and detect mechanical complications 1
• Long-term follow-up to monitor for recurrent ischemia and heart failure 1

Pitfalls and Caveats

• ST elevation after cardiac surgery may be non-specific but should never be dismissed without proper evaluation 2
• Streptokinase should not be readministered to treat recurrent ischemia in patients who received a non-fibrin-specific fibrinolytic agent more than 5 days previously 1
• The benefits of revascularization must be weighed against the risk of postoperative bleeding, particularly when anticoagulation and antiplatelet therapy are required 1
• Consider non-coronary causes of ST elevation post-cardiac surgery, such as Takotsubo cardiomyopathy, which may mimic acute coronary syndrome 5