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Abstract
Coronary heart disease (CHD) is the leading cause of morbidity and mortality worldwide. For a large number of patients with CHD, coronary artery bypass graft (CABG) surgery remains the preferred strategy for coronary revascularization. Over the last 10 years, the number of high-risk patients undergoing CABG surgery has increased significantly, resulting in worse clinical outcomes in this patient group. This appears to be related to the ageing population, increased co-morbidities (such as diabetes, obesity, hypertension, stroke), concomitant valve disease, and advances in percutaneous coronary intervention which have resulted in patients with more complex coronary artery disease undergoing surgery. These high-risk patients are more susceptible to peri-operative myocardial injury and infarction (PMI), a major cause of which is acute global ischaemia/reperfusion injury arising from inadequate myocardial protection during CABG surgery. Therefore, novel therapeutic strategies are required to protect the heart in this high-risk patient group. In this article, we review the aetiology of PMI during CABG surgery, its diagnosis and clinical significance, and the endogenous and pharmacological therapeutic strategies available for preventing it. By improving cardioprotection during CABG surgery, we may be able to reduce PMI, preserve left ventricular systolic function, and reduce morbidity and mortality in these high-risk patients with CHD.
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Affiliation(s)
- Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College, London WC1E 6HX, UK
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, DiSesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Jacobs AK, Anderson JL, Albert N, Creager MA, Ettinger SM, Guyton RA, Halperin JL, Hochman JS, Kushner FG, Ohman EM, Stevenson W, Yancy CW. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2012; 143:4-34. [PMID: 22172748 DOI: 10.1016/j.jtcvs.2011.10.015] [Citation(s) in RCA: 197] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Girerd N, Pibarot P, Daleau P, Voisine P, O'Hara G, Després JP, Mathieu P. Statins reduce short- and long-term mortality associated with postoperative atrial fibrillation after coronary artery bypass grafting: impact of postoperative atrial fibrillation and statin therapy on survival. Clin Cardiol 2012; 35:430-6. [PMID: 22278772 DOI: 10.1002/clc.21008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 10/16/2011] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is a frequent complication of coronary artery bypass grafting (CABG) surgery. The objective of this study was to determine the impact of POAF on both short- and long-term mortality following isolated CABG. HYPOTHESIS POAF is associated with a poorer short and long-term mortality following CABG. METHODS We retrospectively analyzed the preoperative and operative data of 6728 consecutive patients undergoing a first isolated CABG. RESULTS The incidence of POAF was 27.8%. Operative mortality was higher in patients with POAF compared to those without POAF (2.3% vs 0.9%, P < 0.001). On multivariate analysis, POAF remained an independent predictor of operative mortality (odds ratio [OR]: 1.78, P = 0.01). Patients with POAF also had reduced long-term survival (6-year survival: 85.3% vs 89.2%, P < 0.001). After adjusting for other predictors of mortality, POAF was significantly associated with increased long-term mortality (hazard ratio [HR]: 1.35, P = 0.04). Of note, after adjustment for potential confounders, statin treatment had a highly protective effect in POAF patients for both operative mortality (OR: 0.38, P = 0.003) and long-term mortality (HR: 0.62, P = 0.03), whereas it had no significant effect in patients without POAF. CONCLUSIONS POAF is an independent predictor of both short- and long-term mortality following CABG. Moreover, statin therapy was independently associated with better survival in patients with POAF.
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:2610-42. [PMID: 22064600 DOI: 10.1161/cir.0b013e31823b5fee] [Citation(s) in RCA: 337] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol 2011; 58:e123-210. [PMID: 22070836 DOI: 10.1016/j.jacc.2011.08.009] [Citation(s) in RCA: 576] [Impact Index Per Article: 44.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 124:e652-735. [PMID: 22064599 DOI: 10.1161/cir.0b013e31823c074e] [Citation(s) in RCA: 390] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Youn YN, Park SY, Hwang Y, Joo HC, Yoo KJ. Impact of High-Dose Statin Pretreatment in Patients with Stable Angina during Off-Pump Coronary Artery Bypass. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2011; 44:208-14. [PMID: 22263153 PMCID: PMC3249304 DOI: 10.5090/kjtcs.2011.44.3.208] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2011] [Revised: 03/12/2011] [Accepted: 05/19/2011] [Indexed: 01/19/2023]
Abstract
BACKGROUND Periprocedural treatment with high-dose statins is known to have cardioprotective and pleiotropic effects, such as anti-thrombotic and anti-inflammatory actions. We aimed to assess the efficacy of high-dose rosuvastatin loading in patients with stable angina undergoing off-pump coronary artery bypass grafting (OPCAB). MATERIALS AND METHODS A total of 142 patients with stable angina who were scheduled to undergo surgical myocardial revascularization were randomized to receive either pre-treatment with 60-mg rosuvastatin (rosuvastatin group, n=71) or no pre-treatment (control group, n=71) before OPCAB. The primary endpoint was the 30-day incidence of major adverse cardiac events (MACEs). The secondary endpoint was the change in the degree of myocardial ischemia as evaluated with creatine kinase-myocardial band (CK-MB) and troponin T (TnT). RESULTS There were no significant intergroup differences in preoperative risk factors or operative strategy. MACEs within 30 days after OPCAB occurred in one patient (1.4%) in the rosuvastatin group and four patients (5.6%) in the control group, respectively (p=0.37). Preoperative CK-MB and TnT were not different between the groups. After OPCAB, the mean maximum CK-MB was significantly higher in the control group (rosuvastatin group 10.7±9.75 ng/mL, control group 14.6±12.9 ng/mL, p=0.04). Furthermore, the mean levels of maximum TnT were significantly higher in the control group (rosuvastatin group 0.18±0.16 ng/mL, control group 0.39±0.70 ng/mL, p=0.02). CONCLUSION Our findings suggest that high-dose rosuvastatin loading before OPCAB surgery did not result in a significant reduction of 30-day MACEs. However, high-dose rosuvastatin reduced myocardial ischemia after OPCAB.
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Affiliation(s)
- Young-Nam Youn
- Division of Cardiovascular Surgery, Yonsei Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Korea
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Molnar AO, Coca SG, Devereaux PJ, Jain AK, Kitchlu A, Luo J, Parikh CR, Paterson JM, Siddiqui N, Wald R, Walsh M, Garg AX. Statin use associates with a lower incidence of acute kidney injury after major elective surgery. J Am Soc Nephrol 2011; 22:939-46. [PMID: 21493769 DOI: 10.1681/asn.2010050442] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Statins abrogate ischemic renal injury in animal studies but whether they are renoprotective in humans is unknown. We conducted a population-based retrospective cohort study that included 213,347 older patients who underwent major elective surgery in the province of Ontario, Canada from 1995 to 2008. During the first 14 postoperative days, 1.9% (4020 patients), developed acute kidney injury and 0.5% (1173 patients), required acute dialysis. The 30-day mortality rate was 2.8% (5974 patients). Prior to surgery, 32% of patients were taking a statin. After statistical adjustment for patient and surgical characteristics, statin use associated with 16% lower odds of acute kidney injury (OR, 0.84; 95% CI, 0.79 to 0.90), 17% lower odds of acute dialysis (OR, 0.83; 95% CI, 0.72 to 0.95), and 21% lower odds of mortality (OR, 0.79; 95% CI, 0.74 to 0.85). Propensity score matching produced similar results. These data suggest that statins may protect against renal complications after major elective surgery and reduce perioperative mortality.
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Affiliation(s)
- Amber O Molnar
- Division of Nephrology, Department of Medicine, University of Western Ontario, London, Canada
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Mithani S, Kuskowski M, Slinin Y, Ishani A, McFalls E, Adabag S. Dose-Dependent Effect of Statins on the Incidence of Acute Kidney Injury After Cardiac Surgery. Ann Thorac Surg 2011; 91:520-5. [DOI: 10.1016/j.athoracsur.2010.10.061] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Revised: 10/20/2010] [Accepted: 10/22/2010] [Indexed: 02/01/2023]
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Bolesta S, Uhrin LM, Guzek JR. Preoperative Statins and Acute Kidney Injury After Cardiac Surgery: Utilization of a Consensus Definition of Acute Kidney Injury. Ann Pharmacother 2011; 45:23-30. [DOI: 10.1345/aph.1p384] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Previous trials investigating preoperative statin use for prevention of acute kidney injury following cardiovascular surgery were limited to patients undergoing a specific procedure and many used nonconsensus definitions of acute kidney injury. Objective To use a consensus definition of acute kidney injury for evaluating the association of preoperative statin use with the development of acute kidney injury following cardiac surgery utilizing cardiopulmonary bypass. Methods We retrospectively evaluated a cohort of 667 patients ≥18 years who underwent any cardiac surgery on cardiopulmonary bypass between April 2007 and May 2009 at Mercy Hospital in Scranton, PA. Patients were excluded if they were receiving preoperative renal replacement therapy, had stage 5 chronic kidney disease, or did not have a postoperative serum creatinine level assessed. The primary outcome was the odds of developing acute kidney injury given the use of preoperative statins. Acute kidney injury was defined based on the Acute Kidney Injury Network criteria as either an absolute increase in serum creatinine of ≥0.3 mg/dL or 1.5 times baseline, or the need for postoperative renal replacement therapy. Results: The final analysis included 563 patients; 356 were receiving preoperative statins. The incidence of acute kidney injury was 35.1% in the statin group and 26.1% in the non-statin group. On univariate analysis statins were associated with an increase in the odds of acute kidney injury (OR 1.53; 95% CI 1.05 to 2.24). Multivariate logistic regression did not demonstrate an association of statins with acute kidney injury (OR 1.36; 95% CI 0.904 to 2.05). Repeating the analysis using 312 propensity score–matched patients also showed no association of statins with acute kidney injury (OR 1.17; 95% CI 0.715 to 1.93). Conclusions: Our findings do not support the hypothesis that preoperative statin use is associated with a decrease in the incidence of acute kidney injury following cardiac surgery utilizing cardiopulmonary bypass.
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Affiliation(s)
- Scott Bolesta
- Department of Pharmacy Practice, Wilkes University, Wilkes-Barre, PA; Clinical Pharmacist, Department of Pharmacy, Mercy Hospital, Scranton, PA
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Allou N, Augustin P, Dufour G, Tini L, Ibrahim H, Dilly MP, Montravers P, Wallace J, Provenchère S, Philip I. Preoperative Statin Treatment Is Associated With Reduced Postoperative Mortality After Isolated Cardiac Valve Surgery in High-Risk Patients. J Cardiothorac Vasc Anesth 2010; 24:921-6. [DOI: 10.1053/j.jvca.2010.03.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Indexed: 11/11/2022]
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Abstract
In recent decades, there have been substantial declines in the morbidity and mortality rates of cardiovascular disease. Nonetheless, cardiologists have sometimes been slow to amend prevailing concepts and alter established clinical strategies even when compelling new evidence comes to light. Recent studies have underscored the systemic nature of coronary artery disease, its early age at onset, and its high prevalence in the general population. Prevention and treatment approaches should fully incorporate these concepts. Furthermore, prevention of the most devastating complications of chronic coronary artery disease-sudden death and acute coronary events-should be given the highest priority.
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64
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Antoniades C, Bakogiannis C, Tousoulis D, Reilly S, Zhang MH, Paschalis A, Antonopoulos AS, Demosthenous M, Miliou A, Psarros C, Marinou K, Sfyras N, Economopoulos G, Casadei B, Channon KM, Stefanadis C. Preoperative atorvastatin treatment in CABG patients rapidly improves vein graft redox state by inhibition of Rac1 and NADPH-oxidase activity. Circulation 2010; 122:S66-73. [PMID: 20837928 DOI: 10.1161/circulationaha.109.927376] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Statins improve clinical outcome of patients with atherosclerosis, but their perioperative role in patients undergoing coronary artery bypass grafting (CABG) is unclear. We hypothesized that short-term treatment with atorvastatin before CABG would improve the redox state in saphenous vein grafts (SVGs), independently of low-density lipoprotein cholesterol (LDL)-lowering. METHODS AND RESULTS In a randomized, double-blind controlled trial, 42 statin-naïve patients undergoing elective CABG received atorvastatin 40 mg/d or placebo for 3 days before surgery. Circulating inflammatory markers and malondialdehyde (MDA) were measured before and after treatment. SVG segments were used to determine vascular superoxide (O(2)(*-)) and Rac1 activation. For ex vivo studies, SVG segments from 24 patients were incubated for 6 hours with atorvastatin 0, 5, or 50 μmol/L. Oral atorvastatin reduced vascular basal and NADPH-stimulated O(2)(*-) in SVGs (P<0.05 for all versus placebo) and reduced plasma MDA (P<0.05), independently of LDL-lowering and of changes in inflammatory markers. In SVGs exposed to atorvastatin ex vivo, without exposure to LDL, basal and NADPH-stimulated O(2)(·-) were significantly reduced (P<0.01 for both concentrations versus 0 μmol/L) in association with a striking reduction in Rac1 activation and 1 membrane-bound Rac1 and p67(phox) subunit. The antioxidant effects of atorvastatin were reversed by mevalonate, implying a dependence on vascular HMG-CoA reductase inhibition. CONCLUSIONS Short-term treatment with atorvastatin 40 mg/d before CABG improves redox state in SVGs, by inhibiting vascular Rac1-mediated activation of NADPH-oxidase. These novel findings suggest that statin therapy should be maintained or initiated in patients undergoing CABG, independently of LDL levels. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01013103.
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Affiliation(s)
- Charalambos Antoniades
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.
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Huffmyer JL, Nemergut EC. Reply. J Cardiothorac Vasc Anesth 2010. [DOI: 10.1053/j.jvca.2009.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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66
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Eagle KA, Chopra V. Statins Before Coronary Procedures. J Am Coll Cardiol 2010; 56:1110-2. [DOI: 10.1016/j.jacc.2010.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 04/13/2010] [Indexed: 11/16/2022]
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Meijer P, Wouters CW, van den Broek PHH, de Rooij M, Scheffer GJ, Smits P, Rongen GA. Upregulation of ecto-5'-nucleotidase by rosuvastatin increases the vasodilator response to ischemia. Hypertension 2010; 56:722-7. [PMID: 20679180 DOI: 10.1161/hypertensionaha.110.155689] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
3-Hydroxy-3-methyl-glutaryl-coenzyme A reductase inhibitors (statins) are effective in the primary and secondary prevention of cardiovascular events. Although originally developed to improve lipid profile, statins have demonstrated a surplus of beneficial pleiotropic effects, including improved endothelial function, reduced inflammation, and increased tolerance to ischemia-reperfusion injury. In preclinical studies, increased ecto-5'-nucleotidase activity, the key enzyme in extracellular adenosine formation, plays an important role in these effects. Because human data are absent, we explored the effects of rosuvastatin on ecto-5'-nucleotidase activity and the clinical relevance of increased extracellular adenosine during ischemia in humans in vivo. The forearm vasodilator responses to 3 increasing periods of forearm ischemia (2, 5, and 13 minutes) were determined during placebo and caffeine (an adenosine receptor antagonist) infusion into the brachial artery. At the end of an 8-day treatment period with rosuvastatin (20 mg per day), this whole procedure was repeated. During both experiments, ecto-5'-nucleotidase activity was determined. Vasodilator responses are expressed as the percentage increase in forearm blood flow ratio from baseline. Rosuvastatin increased ecto-5'-nucleotidase activity by 49±17% and enhanced the vasodilator response after 2, 5, and 13 minutes of ischemia in the absence (146±19, 330±26, and 987±133 to 312±77, 566±107, and 1533±267) but not in the presence of caffeine (98±25, 264±54, and 727±111 versus 95±19, 205±34, and 530±62). Rosuvastatin increases extracellular formation of adenosine in humans in vivo probably by enhancing ecto-5'-nucleotidase activity. This action results in the improvement of reactive hyperemia and may further enhance the clinical benefit of statins, in particular in conditions of ischemia.
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Affiliation(s)
- Patrick Meijer
- Departments of Pharmacology-Toxicology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Ruiz-Bailén M, Pérez-Valenzuela J, Ferrezuelo-Mata A, Obra-Cuadra RJ. [Effect of the administration of statins in non-cardiac critical disease]. Med Intensiva 2010; 35:107-16. [PMID: 20630621 DOI: 10.1016/j.medin.2010.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Revised: 05/28/2010] [Accepted: 05/31/2010] [Indexed: 12/18/2022]
Abstract
Administration of statins has been shown to be effective in reducing cardiovascular mortality. Their benefit could expand towards other areas of intensive medicine, it being possible to decrease mortality of the critically ill patient. There are several studies, although without a high level of evidence, that have detected a possible benefit when they are administered as well as clinical deterioration when they are discontinued, compared to those patients who had previously taken them. Even though most of the patients who had previously taken statins did so as primary or secondary prevention, thus having greater comorbidity, overall, a decrease is detected in the mortality of these subgroups. This benefit could be generalized to all the critical conditions, although studies with a higher level of evidence are needed for their adequate comparison.
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Affiliation(s)
- M Ruiz-Bailén
- Departamento de Ciencias de la Salud, Universidad de Jaén, Jaén, Spain.
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Austin PC. Primer on statistical interpretation or methods report card on propensity-score matching in the cardiology literature from 2004 to 2006: a systematic review. Circ Cardiovasc Qual Outcomes 2010; 1:62-7. [PMID: 20031790 DOI: 10.1161/circoutcomes.108.790634] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Propensity-score matching is frequently used in the cardiology literature. Recent systematic reviews have found that this method is, in general, poorly implemented in the medical literature. The study objective was to examine the quality of the implementation of propensity-score matching in the general cardiology literature. METHODS AND RESULTS A total of 44 articles published in the American Heart Journal, the American Journal of Cardiology, Circulation, the European Heart Journal, Heart, the International Journal of Cardiology, and the Journal of the American College of Cardiology between January 1, 2004, and December 31, 2006, were examined. Twenty of the 44 studies did not provide adequate information on how the propensity-score-matched pairs were formed. Fourteen studies did not report whether matching on the propensity score balanced baseline characteristics between treated and untreated subjects in the matched sample. Only 4 studies explicitly used statistical methods appropriate for matched studies to compare baseline characteristics between treated and untreated subjects. Only 11 (25%) of the 44 studies explicitly used statistical methods appropriate for the analysis of matched data when estimating the effect of treatment on the outcomes. Only 2 studies described the matching method used, assessed balance in baseline covariates by appropriate methods, and used appropriate statistical methods to estimate the treatment effect and its significance. CONCLUSIONS Application of propensity-score matching was poor in the cardiology literature. Suggestions for improving the reporting and analysis of studies that use propensity-score matching are provided.
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Affiliation(s)
- Peter C Austin
- Institute for Clinical Evaluative Sciences, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario M4N 3M5, Canada.
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Gan HL, Zhang JQ, Bo P, Wang SX, Lu CS. Statins Decrease Adverse Outcomes in Coronary Artery Bypass for Extensive Coronary Artery Disease as well as Left Main Coronary Stenosis. Cardiovasc Ther 2010; 28:70-9. [DOI: 10.1111/j.1755-5922.2009.00098.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Preoperative C-reactive protein predicts long-term mortality and hospital length of stay after primary, nonemergent coronary artery bypass grafting. Anesthesiology 2010; 112:607-13. [PMID: 20179497 DOI: 10.1097/aln.0b013e3181cea3b5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preoperative C-reactive protein (CRP) levels more than 10 mg/l have been shown to be associated with increased morbidity and mortality after cardiac surgery. We examine the value of preoperative CRP levels less than 10 mg/l for predicting long-term, all-cause mortality and hospital length of stay in surgical patients undergoing primary, nonemergent coronary artery bypass graft-only surgery. METHODS We examined the association between preoperative CRP levels stratified into four categories (< 1, 1-3, 3-10, and > 10 mg/l), and 7-yr all-cause mortality and hospital length of stay in 914 prospectively enrolled primary, nonemergent coronary artery bypass graft-only surgical patients using a proportional hazards regression model. RESULTS Eighty-seven patients (9.5%) died during a mean follow-up period of 4.8 +/- 1.5 yr. After proportional hazards adjustment, the 3-10 and > 10 mg/l preoperative CRP groups were associated with long-term, all-cause mortality (hazards ratios [95% CI]: 2.50 [1.22-5.16], P = 0.01 and 2.66 [1.21-5.80], P = 0.02, respectively) and extended hospital length of stay (1.32 [1.07-1.63], P < 0.001 and 1.27 [1.02-1.62], P = 0.001, respectively). CONCLUSION We demonstrate that preoperative CRP levels as low as 3 mg/l are associated with increased long-term mortality and extended hospital length of stay in relatively lower-acuity patients undergoing primary, nonemergent coronary artery bypass graft-only surgery. These important findings may allow for more objective risk stratification of patients who present for uncomplicated surgical coronary revascularization.
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Preoperative statin is associated with decreased operative mortality in high risk coronary artery bypass patients. J Cardiothorac Surg 2010; 5:8. [PMID: 20181268 PMCID: PMC2841066 DOI: 10.1186/1749-8090-5-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Accepted: 02/24/2010] [Indexed: 12/03/2022] Open
Abstract
Background Statins are widely prescribed to patients with atherosclerosis. A retrospective database analysis was used to examine the role of preoperative statin use in hospital mortality, for patients undergoing isolated coronary artery bypass grafting (CABG.) Methods The study population comprised 2377 patients who had isolated CABG at Allegheny General Hospital between 2000 and 2004. Mean age of the patients was 65 ± 11 years (range 27 to 92 years). 1594 (67%) were male, 5% had previous open heart procedures, and 4% had emergency surgery. 1004 patients (42%) were being treated with a statin at the time of admission. Univariate, bivariate (Chi2, Fisher's Exact and Student's t-tests) and multivariate (stepwise linear regression) analyses were used to evaluate the association of statin use with mortality following CABG. Results Annual prevalence of preoperative statin use was similar over the study period and averaged 40%. Preoperative clinical risk assessment demonstrated a 2% risk of mortality in both the statin and non-statin groups. Operative mortality was 2.4% for all patients, 1.7% for statin users and 2.8% for non-statin users (p < 0.07). Using multivariate analysis, lack of statin use was found to be an independent predictor of mortality in high-risk patients (n = 245, 12.9% vs. 5.6%, p < 0.05). Conclusions Between 2000 and 2004 less than 50% of patients at this institution were receiving statins before admission for isolated CABG. A retrospective analysis of this cohort provides evidence that preoperative statin use is associated with lower operative mortality in high-risk patients.
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Kinoshita T, Asai T, Nishimura O, Hiramatsu N, Suzuki T, Kambara A, Matsubayashi K. Statin for Prevention of Atrial Fibrillation After Off-Pump Coronary Artery Bypass Grafting in Japanese Patients. Circ J 2010; 74:1846-51. [DOI: 10.1253/circj.cj-10-0085] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takeshi Kinoshita
- Division of Cardiovascular Surgery, Shiga University of Medical Science
| | - Tohru Asai
- Division of Cardiovascular Surgery, Shiga University of Medical Science
| | - Osamu Nishimura
- Division of Cardiovascular Surgery, Shiga University of Medical Science
| | | | - Tomoaki Suzuki
- Division of Cardiovascular Surgery, Shiga University of Medical Science
| | - Atsushi Kambara
- Division of Cardiovascular Surgery, Shiga University of Medical Science
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74
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Abstract
Contemporary life, with its sedentary lifestyles, fast foods, processed foodstuff, and desk-bound service employment, is beset by an epidemic of overweight and obese individuals. The World Health Organization reported that worldwide a billion adults are overweight and at least 30% of them are obese. Moreover, increasing numbers of children are obese. In the United States, 2 National Health and Nutrition Examination Surveys of adults aged 20 to 74 years showed that the prevalence of obesity increased from 15% in the 1976 to 1980 survey to 34% in the 2003 to 2004 survey. Obesity and the metabolic syndrome are unfortunately becoming increasingly common perioperative issues. The ultimate aim of caring for such patients is to find ways to minimize the untoward effects of surgery in patients who are obese or have metabolic syndrome.
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Affiliation(s)
- Phillip D Levin
- Department of Anesthesiology and Critical Care Medicine, Hebrew University Medical Center, Hebrew University-Hadassah School of Medicine, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel
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75
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Koenig MA, Grega MA, Bailey MM, Pham LD, Zeger SL, Baumgartner WA, McKhann GM. Statin use and neurologic morbidity after coronary artery bypass grafting: A cohort study. Neurology 2009; 73:2099-106. [PMID: 19907012 DOI: 10.1212/wnl.0b013e3181c677f6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Statin use before surgery has been associated with reduced morbidity and mortality after vascular surgery. The effect of preoperative statin use on stroke and encephalopathy after coronary artery bypass grafting (CABG) is unclear. METHODS A post hoc analysis was undertaken of a prospectively collected cohort of isolated CABG patients over a 10-year period at a single institution. Primary outcomes were stroke and encephalopathy. Univariable analyses identified risk factors for statin use, which were applied to a propensity score model using logistic regression and patients were divided into quintiles of propensity for statin use. Controlling for propensity score quintile, the odds ratio (OR) of combined stroke and encephalopathy (primary endpoint), cardiovascular mortality, myocardial infarction, and length of stay were compared between statin users and nonusers. RESULTS There were 5,121 CABG patients, of whom 2,788 (54%) were taking statin medications preoperatively. Stroke occurred in 166 (3.2%) and encephalopathy in 438 (8.6%), contributing to 604 patients (11.8%) who met the primary endpoint. The unadjusted OR of stroke/encephalopathy in statin users was 1.053 (95% confidence interval [CI] 0.888-1.248, p = 0.582). Adjustment based on propensity score resulted in balance of stroke risk factors among quintiles. The propensity score-adjusted OR of stroke/encephalopathy in statin users was 0.958 (95% CI 0.784-1.170, p = 0.674). There were no significant differences in cardiovascular mortality, myocardial infarction, or length of stay between statin users and otherwise similar nonusers. CONCLUSIONS In this large data cohort study, preoperative statin use was not associated with a decreased incidence of stroke and encephalopathy after coronary artery bypass grafting.
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Affiliation(s)
- M A Koenig
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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76
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Abstract
Contemporary life, with its sedentary lifestyles, fast foods, processed foodstuff, and desk-bound service employment, is beset by an epidemic of overweight and obese individuals. The World Health Organization reported that worldwide a billion adults are overweight and at least 30% of them are obese. Moreover, increasing numbers of children are obese. In the United States, 2 National Health and Nutrition Examination Surveys of adults aged 20 to 74 years showed that the prevalence of obesity increased from 15% in the 1976 to 1980 survey to 34% in the 2003 to 2004 survey. Obesity and the metabolic syndrome are unfortunately becoming increasingly common perioperative issues. The ultimate aim of caring for such patients is to find ways to minimize the untoward effects of surgery in patients who are obese or have metabolic syndrome.
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Affiliation(s)
- Phillip D Levin
- Department of Anesthesiology and Critical Care Medicine, Hebrew University Medical Center, Hebrew University-Hadassah School of Medicine, Kiryat Hadassah, Jerusalem 91120, Israel
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77
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Statins for prevention of atrial fibrillation after cardiac surgery: A systematic literature review. J Thorac Cardiovasc Surg 2009; 138:678-686.e1. [DOI: 10.1016/j.jtcvs.2009.03.054] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2008] [Revised: 03/04/2009] [Accepted: 03/29/2009] [Indexed: 11/21/2022]
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78
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The effect of previous coronary artery stenting on short- and intermediate-term outcome after surgical revascularization in patients with diabetes mellitus. J Thorac Cardiovasc Surg 2009; 138:316-23. [PMID: 19619774 DOI: 10.1016/j.jtcvs.2009.03.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2009] [Revised: 02/20/2009] [Accepted: 03/08/2009] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Percutaneous intervention for coronary revascularization is associated with an increased risk of repeat revascularization, especially in patients with diabetes mellitus. In this study we sought to examine the effect of previous percutaneous intervention on the rate of adverse perioperative outcome and intermediate-term survival in patients undergoing coronary artery bypass surgery. METHODS Between January 1, 2001, and December 31, 2006, 1758 consecutive patients with diabetes mellitus who underwent first-time isolated coronary artery bypass surgery were identified. Survival and major perioperative complications for 1537 patients who did not have prior percutaneous intervention (group 1) were compared with those in 221 patients with prior percutaneous intervention (group 2) after adjusting for baseline risk factors. Vital status was determined by using the National Death Index and Social Security Death Index. Age-adjusted survival at 2 years' follow-up was calculated with the Cox singular proportional hazards model. RESULTS At baseline, group 2 patients had higher incidences of hypercholesterolemia and myocardial infarction. Compared with group 1 patient, group 2 patients had significantly higher operative mortality (adjusted odds ratio, 4.05; 95% confidence interval, 1.41-11.63), perioperative major adverse cardiac events (adjusted odds ratio, 2.72; 95% confidence interval, 1.08-6.85), and atrial fibrillation (adjusted odds ratio, 1.97; 95% confidence interval, 1.29-3.01). Group 2 patients had worse age-adjusted survival at 2 years' follow-up (93.4% vs 87.4%, P < .017). CONCLUSIONS Patients with diabetes mellitus and a history of percutaneous coronary stenting before coronary artery bypass surgery were found to have an increased risk of operative death, increased perioperative complications, and decreased age-adjusted survival at 2 years' follow-up.
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79
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Meijer P, Oyen WJG, Dekker D, van den Broek PHH, Wouters CW, Boerman OC, Scheffer GJ, Smits P, Rongen GA. Rosuvastatin increases extracellular adenosine formation in humans in vivo: a new perspective on cardiovascular protection. Arterioscler Thromb Vasc Biol 2009; 29:963-8. [PMID: 19359665 DOI: 10.1161/atvbaha.108.179622] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Statins may increase extracellular adenosine formation from adenosine monophosphate by enhancing ecto-5'-nucleotidase activity. This theory was tested in humans using dipyridamole-induced vasodilation as a read-out for local adenosine formation. Dipyridamole inhibits the transport of extracellular adenosine into the cytosol resulting in increased extracellular adenosine and subsequent vasodilation. In addition, we studied the effect of statin therapy in a forearm model of ischemia-reperfusion injury. METHODS AND RESULTS Volunteers randomly received rosuvastatin or placebo in a double-blind parallel design (n=21). The forearm vasodilator response to intraarterial dipyridamole was determined in the absence and presence of the adenosine antagonist caffeine. During a separate visit the vasodilator response to nitroprusside and adenosine was established. In addition, healthy men were randomly divided in 3 groups to receive either placebo (n=10), rosuvastatin (n=22), or rosuvastatin combined with intravenous caffeine (n=12). Subsequently, volunteers performed forearm ischemic exercise. At reperfusion, Tc-99m-labeled annexin A5 was infused intravenously and scintigraphic images were acquired, providing an early marker of cell injury. Rosuvastatin treatment significantly increased the vasodilator response to dipyridamole, which was prevented by caffeine. Rosuvastatin did not influence the response to either sodium nitroprusside or adenosine indicating a specific interaction between rosuvastatin and dipyridamole, which does not result from an effect of rosuvastatin on adenosine clearance nor adenosine-receptor affinity or efficacy. Rosuvastatin increased tolerance to ischemia-reperfusion injury, which was attenuated by caffeine. CONCLUSIONS Rosuvastatin increases extracellular adenosine formation, which provides protection against ischemia-reperfusion injury in humans in vivo. Therefore, statins and dipyridamole may interact synergistically.
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Affiliation(s)
- Patrick Meijer
- Radboud University Nijmegen Medical Centre, Department of Pharmacology and Toxicology, Nijmegen, The Netherlands
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80
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Ludman A, Venugopal V, Yellon DM, Hausenloy DJ. Statins and cardioprotection — More than just lipid lowering? Pharmacol Ther 2009; 122:30-43. [DOI: 10.1016/j.pharmthera.2009.01.002] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Indexed: 11/29/2022]
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81
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Huffmyer JL, Mauermann WJ, Thiele RH, Ma JZ, Nemergut EC. Preoperative statin administration is associated with lower mortality and decreased need for postoperative hemodialysis in patients undergoing coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2009; 23:468-73. [PMID: 19157909 DOI: 10.1053/j.jvca.2008.11.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2008] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to examine the effect of perioperative statin administration on renal outcomes after cardiac surgery. DESIGN A retrospective chart review. SETTING A university hospital. PARTICIPANTS Patients presenting for cardiac surgery. INTERVENTIONS The records of 2,760 patients admitted for coronary artery bypass graft (CABG) surgery from 1997 to 2006 were reviewed. In-hospital mortality, the need for renal replacement therapy (RRT), and acute renal failure (ARF) were considered the primary outcomes. Univariate and multiple logistic regression analyses were performed to assess the relationship between each outcome and statin therapy while adjusting for other patient characteristics. MAIN RESULTS Of the 2,760 patients, 1,557 were taking preoperative statins. On univariate analysis, the mortality rate for patients receiving statins was 2.4% versus 4.2% for those not receiving statins (p = 0.008). The requirement for RRT was 1.9% for patients receiving statins versus 3.6% for those not receiving statins (p = 0.011). The incidence of ARF was not statistically significant between groups (28% v 27.5%). On multivariate analysis, statin therapy was associated with a 43% decrease in the risk of death and a 46% decrease in the risk of RRT, but statins were not associated with a decreased risk of ARF. Also, the beneficial effects of statins were age-dependent, with younger patients experiencing a greater advantage. CONCLUSIONS The preoperative use of statins is associated with decreased in-hospital mortality and a reduction in the need for RRT.
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Affiliation(s)
- Julie L Huffmyer
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, VA 22908, USA
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82
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Statin therapy is associated with reduced total and cardiovascular mortality after coronary artery bypass grafting surgery. Coron Artery Dis 2008; 19:619-25. [DOI: 10.1097/mca.0b013e3283142607] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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83
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Kulik A, Brookhart MA, Levin R, Ruel M, Solomon DH, Choudhry NK. Impact of Statin Use on Outcomes After Coronary Artery Bypass Graft Surgery. Circulation 2008; 118:1785-92. [DOI: 10.1161/circulationaha.108.799445] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The benefits of statins have been demonstrated for patients with a remote history of coronary artery bypass grafting (CABG); however, no investigation to date has evaluated whether initiation of statin therapy in the early months after surgery improves clinical outcomes.
Methods and Results—
A retrospective cohort of 7503 Medicare patients ≥65 years of age who underwent CABG (1995–2003) was assembled by use of linked hospital and pharmacy claims data. Rates of all-cause mortality and major adverse cardiovascular events were compared between patients who were (n=1745) and were not (n=5788) prescribed statins within 1 month of CABG discharge. Additional analyses evaluated the impact of statin initiation between 1 and 6 months after surgery. Multivariable and propensity score analysis demonstrated that statin use within 1 month of CABG discharge independently reduced the risk of all-cause mortality (adjusted hazard ratio 0.82, 95% confidence interval 0.72 to 0.94) compared with no statin use. Similarly, statin use within 1 month of CABG discharge independently reduced the risk of major adverse cardiovascular events (adjusted hazard ratio 0.89, 95% confidence interval 0.81 to 0.98). Initiation of statin therapy between 1 and 6 months after CABG discharge was also associated with reductions in major adverse cardiovascular events and mortality; however, outcome rates between early (≤1 month after CABG) and delayed (1 to 6 months after CABG) statin initiation were not significantly different.
Conclusions—
Statin therapy initiated in the early months after hospital discharge independently reduces all-cause mortality and major adverse cardiovascular events after CABG. These findings validate the widespread practice of prescribing long-term statin therapy after CABG.
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Affiliation(s)
- Alexander Kulik
- From the Division of Cardiac Surgery (A.K., M.R.), University of Ottawa Heart Institute, Ottawa, Canada, and the Division of Pharmacoepidemiology and Pharmacoeconomics (M.A.B., R.L., D.H.S., N.K.C.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - M. Alan Brookhart
- From the Division of Cardiac Surgery (A.K., M.R.), University of Ottawa Heart Institute, Ottawa, Canada, and the Division of Pharmacoepidemiology and Pharmacoeconomics (M.A.B., R.L., D.H.S., N.K.C.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Raisa Levin
- From the Division of Cardiac Surgery (A.K., M.R.), University of Ottawa Heart Institute, Ottawa, Canada, and the Division of Pharmacoepidemiology and Pharmacoeconomics (M.A.B., R.L., D.H.S., N.K.C.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Marc Ruel
- From the Division of Cardiac Surgery (A.K., M.R.), University of Ottawa Heart Institute, Ottawa, Canada, and the Division of Pharmacoepidemiology and Pharmacoeconomics (M.A.B., R.L., D.H.S., N.K.C.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Daniel H. Solomon
- From the Division of Cardiac Surgery (A.K., M.R.), University of Ottawa Heart Institute, Ottawa, Canada, and the Division of Pharmacoepidemiology and Pharmacoeconomics (M.A.B., R.L., D.H.S., N.K.C.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Niteesh K. Choudhry
- From the Division of Cardiac Surgery (A.K., M.R.), University of Ottawa Heart Institute, Ottawa, Canada, and the Division of Pharmacoepidemiology and Pharmacoeconomics (M.A.B., R.L., D.H.S., N.K.C.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
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84
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Furukawa Y, Taniguchi R, Ehara N, Ozasa N, Haruna Y, Saito N, Doi T, Hoshino K, Shizuta S, Morimoto T, Imai Y, Teramukai S, Fukushima M, Kita T, Kimura T. Better survival with statin administration after revascularization therapy in Japanese patients with coronary artery disease: perspectives from the CREDO-Kyoto registry. Circ J 2008; 72:1937-45. [PMID: 18948669 DOI: 10.1253/circj.cj-08-0293] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The importance of statins in cardiovascular prevention has been demonstrated in various patient subsets. This study aimed to evaluate the effects of statins on long-term outcomes of Japanese patients undergoing their first coronary revascularization. METHODS AND RESULTS A total of 9,225 patients undergoing their first coronary revascularizations during 2000--2002 were divided into 2 groups according to the use of statins at discharge; patients with acute myocardial infarction were not included. Statins was administered to only 28.5% (n=2,630) of the patients. The median follow-up period was 3.5 years. Patients on statin therapy showed lower all-cause (5.2% vs 10.0%; p<0.0001) and cardiovascular (3.2% vs 6.2%; p<0.0001) mortality than those without statins (n=6,595) by Kaplan-Meier analysis and log-rank test. After adjustment by multivariate analysis according to 29 variables, statin therapy remained as an independent predictor of reduced all-cause (relative risk ratio (RR) 0.71, 95% confidence interval (CI) 0.59-0.86, p=0.0005) and cardiovascular (RR 0.72, 95% CI 0.56-0.91, p=0.0067) mortality. The validity of RR of statin therapy in multivariate analysis was further confirmed by risk adjustment using propensity scores (all-cause mortality: propensity-adjusted RR 0.70, 95% CI 0.58-0.85, p=0.0003; cardiovascular mortality: propensity-adjusted RR 0.70, 95% CI 0.54-0.89, p=0.0038). CONCLUSIONS Statin therapy started at hospital discharge was associated with increased chance of survival in Japanese patients undergoing their first coronary revascularization.
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Affiliation(s)
- Yutaka Furukawa
- Division of Cardiology, Kobe City Medical Center General Hospital, Kobe, Japan.
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85
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Wenger NK. Drugs for cardiovascular disease prevention in women: implications of the AHA Guidelines--2007 Update. Drugs 2008; 68:339-58. [PMID: 18257610 DOI: 10.2165/00003495-200868030-00006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Lifestyle interventions constitute the initial strategy for the primary and secondary prevention of cardiovascular disease in women. However, pharmacotherapy is often indicated for control of major cardiovascular risk factors, and abundant clinical trial data support the morbidity and mortality benefit of a number of categories of drug therapy following a coronary event. Although women have increasingly been enrolled in clinical trials of pharmacotherapy, under representation of women in most research studies limits the gender-specific assessment of outcomes. Equally importantly, recent randomized clinical trial data have highlighted inappropriate preventive therapies for women (i.e. those lacking effectiveness and potentially imparting harm). Decision-making data for drug therapy for women also derive from a number of clinical trials conducted solely in women. The drug classes reviewed in this article include omega-3 fatty acids, aspirin, ACE inhibitors and angiotensin II receptor antagonists or blockers, beta-adrenoceptor antagonists (beta-blockers), aldosterone antagonists, antioxidants, folic acid and vitamins B(6) and B(12), and menopausal hormone therapy and selective estrogen-receptor modulators. Information is sparse regarding specific cardiovascular pharmacotherapies for elderly women, and women of racial and ethnic minorities. Owing to the under representation of the subset of women in many trials, analysis by age, race and ethnicity is not appropriate. This information gap presents a major challenge for future studies, as these subgroups constitute populations of women at high cardiovascular risk.
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Affiliation(s)
- Nanette K Wenger
- Emory University School of Medicine, Atlanta, Georgia, USAGrady Memorial Hospital, Atlanta, Georgia, USAEmory Heart and Vascular Center, Atlanta, Georgia 30303, USA.
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86
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Lisle TC, Barrett KM, Gazoni LM, Swenson BR, Scott CD, Kazemi A, Kern JA, Peeler BB, Kron IL, Johnston KC. Timing of stroke after cardiopulmonary bypass determines mortality. Ann Thorac Surg 2008; 85:1556-62; discussion 1562-3. [PMID: 18442537 DOI: 10.1016/j.athoracsur.2008.02.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2007] [Revised: 02/07/2008] [Accepted: 02/08/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND Stroke is an important complication of cardiopulmonary bypass (CPB). This study determined if the timing of stroke events after CPB predicted stroke-related mortality or rehabilitation needs at hospital discharge. METHODS We performed a retrospective review of 7201 consecutive cardiac surgical patients during a 10-year period and identified 202 strokes. Postoperative stroke after CPB was classified as early (< or = 24 hours) or late (> 24 hours). Data were collected on patient characteristics, intraoperative variables and outcomes, postoperative course, stroke severity, and discharge status, including death from stroke. Logistic regression analysis was used to assess the relationship between the timing of stroke and discharge status after adjusting for clinically relevant factors. RESULTS The stroke incidence was 2.8%. Postoperative strokes occurred within 24 hours in 22.8% (46 of 202) and after 24 hours in 77.2% (156 of 202). Factors found in logistic regression analysis to be independently associated with stroke-related death included stroke within 24 hours postoperatively (odds ratio [OR], 9.16; p < 0.0001), preoperative chronic renal insufficiency (OR, 4.46; p = 0.01), and National Institute of Health Stroke Scale (NIHSS) score (OR, 1.16 per NIHSS point increase; p < 0.0001). Among survivors, early stroke was associated with greater rehabilitation needs (p < 0.001). CONCLUSIONS Early stroke after CPB is independently associated with higher stroke-related death and is associated with increased need for skilled rehabilitation at discharge. Neuroprotective strategies aimed at reducing early postoperative stroke may positively impact death and neurologic disability after CPB.
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Affiliation(s)
- Turner C Lisle
- Department of Surgery, University of Virginia, Charlottesville, Virginia 22908, USA.
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87
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Fedoruk LM, Wang H, Conaway MR, Kron IL, Johnston KC. Statin therapy improves outcomes after valvular heart surgery. Ann Thorac Surg 2008; 85:1521-5; discussion 1525-6. [PMID: 18442531 PMCID: PMC2747026 DOI: 10.1016/j.athoracsur.2008.01.078] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 01/20/2008] [Accepted: 01/22/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND The beneficial effects of 3-hydroxy-3-methylglutaryl coenzyme A (HMG Co-A) reductase inhibitors (statins) in patients undergoing coronary artery bypass grafting have been recognized. Reduced mortality rates and clinical events have been demonstrated. These outcomes were examined in patients taking statins who underwent cardiac valve operations. METHODS This retrospective study included 447 consecutive patients undergoing valve operations between July 2004 and February 2006; 203 patients (45.6%) received statins preoperatively and postoperatively vs 244 who did not. Preoperative risk factors and outcome data for both cohorts were compared. Primary outcomes included 30-day mortality, renal failure, and postoperative stroke. RESULTS The statin group had more comorbidities. Although they had increased risk factors, including previous stroke (30 of 203 vs 16 of 244, p = 0.004), diabetes (66 of 203 vs 32 of 244, p < 0.0001), cerebrovascular disease (45 of 203 vs 24 of 244, p = 0.003), and dyslipidemia (191 of 203 vs 63 of 244, p < 0.0001), they had better outcomes. The unadjusted odds ratio (OR) for the composite end point of death/stroke/renal failure was 1.90 (95% confidence interval [CI], 0.95 to 3.76; p = 0.068) favoring the statin group. By univariate analysis, the adjusted OR for the composite end point demonstrated a benefit with statin therapy: diabetes, 2.29 (95% CI, 1.16 to 4.71; p = 0.024); stroke, 2.15 (95% CI, 1.06 to 4.35; p = 0.034); and renal dysfunction, 2.05 (95% CI, 1.02 to 4.13; p = 0.045). CONCLUSIONS Statin therapy in this population undergoing cardiac valve procedures was associated with decreased postoperative morbidity and death. The mechanism may be independent of statins' lipid-lowering effects. A prospective, randomized-control trial of statin therapy in this population is warranted.
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Affiliation(s)
- Lynn M Fedoruk
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia 22908-0679, USA.
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88
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Virani SS, Nambi V, Razavi M, Lee VV, Elayda M, Wilson JM, Ballantyne CM. Preoperative statin therapy is not associated with a decrease in the incidence of postoperative atrial fibrillation in patients undergoing cardiac surgery. Am Heart J 2008; 155:541-6. [PMID: 18294494 DOI: 10.1016/j.ahj.2007.10.027] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Accepted: 10/23/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) after cardiac surgery is associated with significant morbidity. We investigated whether preoperative statin therapy was associated with decreased incidence of postoperative AF in patients undergoing cardiac surgery, including isolated valve surgery and patients with low ejection fraction (EF). METHODS A retrospective study of consecutive patients without history of AF (n = 4044) who underwent cardiac surgeries at St. Luke's Episcopal Hospital (Houston, TX), from January 1, 2003, through April 30, 2006, was conducted. Postoperative AF was assessed by continuous telemetry monitoring during hospitalization for cardiac surgery. RESULTS A total of 2096 patients (52%) received preoperative statins. Atrial fibrillation occurred in 1270 patients (31.4% in both the statin and nonstatin groups). In multivariate regression analysis, age >65 years, history of valvular heart disease, rheumatic disease, pulmonary disease, and New York Heart Association class III/IV were independent predictors of increased risk, whereas female sex was associated with decreased risk. Preoperative statin therapy was not associated with decreased risk in the entire cohort (odds ratio [OR] 1.13, 95% confidence interval [CI] 0.98-1.31) or in subgroups undergoing isolated coronary artery bypass grafting (OR 1.16, 95% CI 0.97-1.43), isolated valve surgery (OR 1.09, 95% CI 0.81-1.46), or both (OR 1.09, 95% CI 0.72-1.65), or the subgroup with EF <35% (OR 1.23, 95% CI 0.84-1.82). After propensity score analysis (n = 867 patients in each group), preoperative statin therapy was not associated with decreased AF incidence (OR 1.14, 95% CI 0.92-1.41). CONCLUSIONS Preoperative statin therapy was not associated with decreased incidence of postoperative AF in patients undergoing cardiac surgery, including patients with low EF.
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Affiliation(s)
- Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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89
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Levin AI. Till death us do part? Postoperative statin discontinuation. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2008. [DOI: 10.1080/22201173.2008.10872514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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90
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Thielmann M, Neuhäuser M, Marr A, Jaeger BR, Wendt D, Schuetze B, Kamler M, Massoudy P, Erbel R, Jakob H. Lipid-lowering effect of preoperative statin therapy on postoperative major adverse cardiac events after coronary artery bypass surgery. J Thorac Cardiovasc Surg 2007; 134:1143-9. [DOI: 10.1016/j.jtcvs.2007.07.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2007] [Revised: 07/14/2007] [Accepted: 07/26/2007] [Indexed: 11/26/2022]
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Merla R, Daher IN, Ye Y, Uretsky BF, Birnbaum Y. Pretreatment with statins may reduce cardiovascular morbidity and mortality after elective surgery and percutaneous coronary intervention: clinical evidence and possible underlying mechanisms. Am Heart J 2007; 154:391-402. [PMID: 17643594 DOI: 10.1016/j.ahj.2007.04.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2006] [Accepted: 04/11/2007] [Indexed: 11/27/2022]
Abstract
After Murry et al (Circulation 1986;74:1124) described ischemic preconditioning in 1986, numerous pharmacologic agents with effects simulating ischemic preconditioning have been identified. With the exception of beta-blockers, most such agents have no proven clinical benefit in the setting of myocardial ischemia. The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) have been consistently demonstrated to reduce myocardial injury, morbidity, and mortality in the clinical setting, both perioperatively and after percutaneous coronary intervention. Although the precise mechanism underlying their additional protective effect is not yet fully understood, it appears to be immediate in action and independent of cholesterol lowering. Experimental data from several animal models of ischemia and reperfusion have demonstrated an infarct size reduction with prior statin administration. At the cellular level, statins activate the phosphoinositol-3 kinase and Akt signaling cascade. Statins also increase expression and activity of endothelial nitric oxide synthase, inducible nitric oxide synthase, ecto-5'-nucleotidase, cyclooxygenase-2, and other prostaglandin synthesis pathway enzymes. However, when given by oral route to animals, relatively high dose of statins is needed to exert maximal protective effect. Understanding the underlying mechanism may enable to maximize the protective effect by using drug combination with synergistic activity and to avoid medications that may interfere with the protective effect of statins (ie, selective and nonselective cyclooxygenase-2 inhibition). Future clinical applications include preoperative and periprocedural risk reduction.
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Affiliation(s)
- Ramanna Merla
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX 77555, USA
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92
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Liakopoulos OJ, Wahlers T. Statins and early clinical outcome after coronary artery bypass grafting. ACTA ACUST UNITED AC 2007. [DOI: 10.2217/17460875.2.4.395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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93
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Levin AI, Coetzee AR. Statins and perioperative myocardial infarction. Mechanisms of action. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2007. [DOI: 10.1080/22201173.2007.10872496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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94
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Sethi M, Collard CD. Perioperative Statin Therapy: Are Formal Guidelines and Physician Education Needed? Anesth Analg 2007; 104:1322-4. [PMID: 17513619 DOI: 10.1213/01.ane.0000264064.19141.f2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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95
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Palmerini T, Marzocchi A, Marrozzini C, Reggiani LB, Savini C, Marinelli G, Di Bartolomeo R, Branzi A. Preoperative C-reactive protein levels predict 9-month mortality after coronary artery bypass grafting surgery for the treatment of left main coronary artery stenosis. Eur J Cardiothorac Surg 2007; 31:685-90. [PMID: 17236785 DOI: 10.1016/j.ejcts.2006.12.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2006] [Revised: 12/20/2006] [Accepted: 12/22/2006] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Preprocedural levels of C-reactive protein predict mid-term mortality after percutaneous coronary intervention for the treatment of unprotected left main coronary artery stenosis. However, there are no data regarding the impact of C-reactive protein on mid-term mortality in patients with unprotected left main coronary artery stenosis treated with coronary artery bypass graft. METHODS The predictive value of preoperative C-reactive protein levels, leukocyte counts, and fibrinogen levels were evaluated in a series of 108 patients who underwent coronary artery bypass graft surgery at our Institution from 1st January 2002 to 31st April 2005. Patients were divided in two groups: Group 1 included patients with C-reactive protein levels in quartiles IV (C-reactive protein levels > or =1.22mg/dl) and Group 2 included patients with C-reactive protein levels in quartiles I+II+III. RESULTS At 9-month follow-up the rate of mortality was 25.9% in Group 1 and 4.9% in Group 2 (hazard ratio=5.86, 95% confidence intervals=1.71-20.03; p=0.005). In all patients who had cardiac mortality, C-reactive protein levels were >0.5mg/dl. In the multivariate analysis age >75 years, peripheral vascular disease and C-reactive protein quartiles were the only independent predictors of mortality. CONCLUSIONS Elevated preoperative levels of C-reactive protein indicate an increased risk of death after coronary artery bypass graft surgery for the treatment of unprotected left main coronary artery stenosis. Inflammatory risk assessment in patients with unprotected left main coronary artery stenosis provides incremental prognostic value for adequate preoperative patient stratification.
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Affiliation(s)
- Tullio Palmerini
- Department of Cardiology, Policlinico S Orsola, University of Bologna, Italy.
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96
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Dunkelgrun M, Schouten O, Feringa HH, Vidakovic R, Poldermans D. Beneficial effects of statins on perioperative cardiovascular outcome. Curr Opin Anaesthesiol 2006; 19:418-22. [PMID: 16829724 DOI: 10.1097/01.aco.0000236142.53969.7e] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review evaluates clinical and experimental articles that have recently been published on the cardioprotective effect of perioperative statin therapy. RECENT FINDINGS Perioperative statin therapy improves short and long-term cardiac outcome following noncardiac surgery. This cardiovascular protection has been attributed to the so-called pleiotropic effects, which have a positive effect on plaque stability. With no clinical studies reporting an increased incidence of adverse effects of perioperative statin use, it appears to be a safe and helpful therapeutic option. SUMMARY Perioperative statin therapy may stabilize coronary plaques due to pleiotropic effects and results in a reduction of perioperative cardiovascular complications.
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97
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Collard CD, Body SC, Shernan SK, Wang S, Mangano DT. Preoperative statin therapy is associated with reduced cardiac mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2006; 132:392-400. [PMID: 16872968 DOI: 10.1016/j.jtcvs.2006.04.009] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2005] [Revised: 04/24/2006] [Accepted: 04/27/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Statin therapy in ambulatory populations is associated with a significant reduction in adverse cardiovascular events, including death and myocardial infarction. Much less is known about the beneficial effects of statins on acute perioperative cardiovascular events. The purpose of this study was to determine whether preoperative statin therapy is associated with a reduced risk of early cardiac death or nonfatal, in-hospital postoperative myocardial infarction after primary, elective coronary artery bypass graft surgery requiring cardiopulmonary bypass. METHODS The Multicenter Study of Perioperative Ischemia (McSPI) Epidemiology II Study was a prospective, longitudinal study of 5436 patients undergoing coronary artery bypass graft surgery between November 1996 and June 2000 at 70 centers in 17 countries. The present study consisted of a pre-specified subset of these subjects divided into patients receiving (n = 1352) and not receiving (n = 1314) preoperative statin therapy. To control for potential bias related to use of statin therapy, the study estimated propensity scores by logistic regression to determine the predicted probability of inclusion in the "statin" group. Multivariate, stepwise logistic regression was then performed, controlling for patient demographics, medical history, operative characteristics, and propensity score to determine whether preoperative statin therapy was independently associated with a reduction in the risk of early (DOS-POD3) cardiac death and/or nonfatal, in-hospital postoperative myocardial infarction. RESULTS Preoperative statin therapy was independently associated with a significant reduction (adjusted odds ratio [OR] 0.25; 95% confidence intervals [CI] 0.07-0.87) in the risk of early cardiac death after primary, elective coronary bypass surgery (0.3% vs 1.4%; P < .03), but was not associated with a reduced risk of postoperative nonfatal, in-hospital myocardial infarction (7.9% vs 6.2%; P = not significant). Discontinuation of statin therapy after surgery was independently associated with a significant increase in late (POD4-discharge) all-cause mortality (adjusted OR 2.64; 95% CI 1.32-5.26) compared with continuation of statin therapy (2.64% vs 0.60%; P < .01). This was true even when controlling for the postoperative discontinuation of aspirin, beta-blocker, or angiotensin-converting enzyme inhibitor therapy. Discontinuation of statin therapy after surgery was also independently associated with a significant increase in late cardiac mortality (adjusted OR 2.95; 95% CI 1.31-6.66) compared with continuation of statin therapy (1.91% vs 0.45%; P < 0.01). CONCLUSIONS Preoperative statin use is associated with reduced cardiac mortality after primary, elective coronary artery bypass grafting. Postoperative statin discontinuation is associated with increased in-hospital mortality. Although further randomized trials are needed to confirm these findings, these data suggest the importance of perioperative statin administration.
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Affiliation(s)
- Charles D Collard
- Baylor College of Medicine, Division of Cardiovascular Anesthesiology, Texas Heart Institute, St Luke's Episcopal Hospital, Houston, Tex, USA.
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98
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Hindler K, Eltzschig HK, Fox AA, Body SC, Shernan SK, Collard CD. Influence of statins on perioperative outcomes. J Cardiothorac Vasc Anesth 2006; 20:251-8. [PMID: 16616673 DOI: 10.1053/j.jvca.2005.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2005] [Indexed: 11/11/2022]
Affiliation(s)
- Katja Hindler
- Division of Cardiovascular Anesthesia, Texas Heart Institute at Saint Luke's Episcopal Hospital, Houston, TX 77030, USA
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99
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Baillard C. Conduite à tenir concernant le traitement médicamenteux des patients adressés pour chirurgie programmée. ACTA ACUST UNITED AC 2005; 24:1360-74. [PMID: 16099124 DOI: 10.1016/j.annfar.2005.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Accepted: 06/15/2005] [Indexed: 10/25/2022]
Abstract
This review focuses on potential drug interactions between anaesthetic drugs or techniques and chronic medications in patients scheduled for surgery. The vast majority of therapeutics can be continued until the morning of surgery. However, for some drugs such as ACE inhibitors, there is strong evidence to recommend their discontinuation prior to surgery. When juged necessary, interruption of chronic therapeutic needs to be anticipated and planned. In the other hand, for other drugs such as beta-blockers or L-Dopa, acute withdrawal is associated with documented adverse outcome. As a result, such drugs have to be continuing throughout the operative period. Although a general consensus exists for many medications, there are still controverses as to the management of antithrombotic drugs and some central nervous system agents. Advances in anaesthesia include knowledge on the mechanisms involved in drug interactions, which allows us to improve the preoperative management of chronic therapeutics.
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Affiliation(s)
- C Baillard
- Service d'anesthésie-réanimation, UPRES 39-04, hôpital Avicenne, 125, avenue de Stalingrad, 93009 Bobigny, France.
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100
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Thielmann M, Massoudy P, Neuhäuser M, Knipp S, Kamler M, Piotrowski J, Mann K, Jakob H. Prognostic Value of Preoperative Cardiac Troponin I in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Undergoing Coronary Artery Bypass Surgery. Chest 2005. [DOI: 10.1016/s0012-3692(15)52926-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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