Year : 2010  |  Volume : 13  |  Issue : 3  |  Page : 268--269

To evaluate the heart or not in emergency neurosurgical head-injured patients with ST elevation


Amit Jain, Neeti Dogra, Kishore Mangal 
 Department of Anaesthesia & Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Amit Jain
Department of Anaesthesia & Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh
India




How to cite this article:
Jain A, Dogra N, Mangal K. To evaluate the heart or not in emergency neurosurgical head-injured patients with ST elevation.Ann Card Anaesth 2010;13:268-269


How to cite this URL:
Jain A, Dogra N, Mangal K. To evaluate the heart or not in emergency neurosurgical head-injured patients with ST elevation. Ann Card Anaesth [serial online] 2010 [cited 2022 Jun 26 ];13:268-269
Available from: https://www.annals.in/text.asp?2010/13/3/268/69073


Full Text

The Editor,

We read with interest the letter to the editor, "ST elevation in a head-injury patient for emergency neurosurgery: Do we routinely need a cardiac evaluation?" [1] The inference of the authors seems simple, yet debatable. The presence of ST elevation signifying the possibility of myocardial ischemia cannot be denied. Further, in head injury patients, echocardiographic findings of myocardial dysfunction have been well documented. [2] Left ventricular wall motion may be significantly decreased in patients with subarachanoid hemorrhage (SAH) and ST elevation compared to those without. [3] .Naidech et al., observed elevated levels of cardiac troponin (cTn)-a 100% sensitive and specific marker for cardiac injury-in up to 20% of patients with aneurysmal SAH. [4] They recommended routine measurement of troponin I (cTI) in SAH patients who present with electrocardiographic changes or clinical signs.of potential cardiovascular dysfunction. Acute cTI elevation >2.0 μg/L after SAH should trigger a screening echocardiogram and may be useful in identifying patients who might benefit from invasive hemodynamic monitoring in the perioperative period. [4] A recent metaanalysis revealed that the markers for cardiac damage and dysfunction are associated.with an increased risk of hypotension requiring vasopressor therapy, delayed cerebral ischemia, poor neurological outcome and death after SAH. [5] Therefore, myocardial injury may occur in patients with SAH, and may be responsible for unstable hemodynamics during the perioperative period in such patients. Although the authors were fortunate that their patient had good neurological outcome, the need for inotropic support following induction of anesthesia in the described case was suggestive of significant cardiac risk.

The need for, and value of, preoperative cardiac evaluation will also depend on the urgency of surgery. In case of emergency surgical procedures, such as those for ruptured abdominal aortic aneurysm, major trauma or perforated viscus, cardiac evaluation will not change the course and result of the intervention, but may influence the management in the immediate postoperative period. A head-injured patient with acute subdural hematoma is possibly such a condition. [6] Nevertheless, the presence of ST-segment elevation raises two anesthetic issues: firstly, the optimum timing for induction of general anesthesia and surgery and, secondly, the management of the possible risk of perioperative cardiovascular deterioration. Myocardial injury in the recent past has been consistently identified as risk factors for perioperative cardiac events. [6] Hence, the argument on whether preoperative cardiology consultation needs to be obtained or not is rather unsubstantiated. The presence of ST elevation certainly raises an alarm for the risk of perioperative cardiovascular complications. Measures to minimize intraoperative cardiac risk should be considered, such as using invasive hemodynamic monitoring, avoiding myocardial depressant agents and maintaining optimal myocardial oxygen supply and demand. One should be prepared to manage any event of hemodynamic instability with vasopressors and cardiotonic drugs.

In conclusion, we suggest that undertaking comprehensive cardiac evaluation (including echocardiography) and cTn estimation prior to emergency neurosurgical procedures in patients with ST elevation may prove to be of benefit to them. The controversy about this issue may be solved by further studies related to this issue.

References

1Bhagat H, Chauhan H, Dash HH. ST elevation in a head-injured patient for emergency neurosurgery: do we routinely need a cardiac evaluation? Ann Card Anaesth 2010;13:73-4.
2Bahloul M, Chaari AN, Kallel H, Khabir A, Ayadi A, Charfeddine H, et al. Neurogenic pulmonary edema due to traumatic brain injury: Evidence of cardiac dysfunction. Am J Crit Care 2006;15:462-70.
3Kono T, Morita H, Kuroiwa T, Onaka H, Takatsuka H, Fujiwara A. Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: Neurogenic stunned myocardium. J Am Coll Cardiol 1994;24:636-40.
4Naidech AM, Kreiter KT, Janjua N, Ostapkovich ND, Parra A, Commichau C, et al. Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage. Circulation 2005;112:2851-6.
5van der Bilt IA, Hasan D, Vandertop WP, Wilde AA, Algra A, Visser FC, et al. Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage: A meta-analysis. Neurology 2009;72:635-42.
6Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J 2009;30:2769-812.