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102
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Alvarez Escudero J, Calvo Vecino JM, Veiras S, García R, González A. Clinical Practice Guideline (CPG). Recommendations on strategy for reducing risk of heart failure patients requiring noncardiac surgery: reducing risk of heart failure patients in noncardiac surgery. ACTA ACUST UNITED AC 2015; 62:359-419. [PMID: 26164471 DOI: 10.1016/j.redar.2015.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/04/2015] [Indexed: 12/29/2022]
Affiliation(s)
- J Alvarez Escudero
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - J M Calvo Vecino
- Professor and Head of the Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain; Associated Professor and Head of the Department of Anesthesiology, Infanta Leonor University Hospital, Complutense University of Madrid, Madrid, Spain.
| | - S Veiras
- Department of Anesthesiology, University Hospital, Santiago de Compostela, La Coruña, Spain
| | - R García
- Department of Anesthesiology, Puerta del Mar University Hospital. Cadiz, Spain
| | - A González
- Department of Anesthesiology, Puerta de Hierro University Hospital. Madrid, Spain
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103
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Cole GD, Shun-Shin MJ, Nowbar AN, Buell KG, Al-Mayahi F, Zargaran D, Mahmood S, Singh B, Mielewczik M, Francis DP. Difficulty in detecting discrepancies in a clinical trial report: 260-reader evaluation. Int J Epidemiol 2015; 44:862-9. [PMID: 26174517 PMCID: PMC4521134 DOI: 10.1093/ije/dyv114] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2015] [Indexed: 01/09/2023] Open
Abstract
Background: Scientific literature can contain errors. Discrepancies, defined as two or more statements or results that cannot both be true, may be a signal of problems with a trial report. In this study, we report how many discrepancies are detected by a large panel of readers examining a trial report containing a large number of discrepancies. Methods: We approached a convenience sample of 343 journal readers in seven countries, and invited them in person to participate in a study. They were asked to examine the tables and figures of one published article for discrepancies. 260 participants agreed, ranging from medical students to professors. The discrepancies they identified were tabulated and counted. There were 39 different discrepancies identified. We evaluated the probability of discrepancy identification, and whether more time spent or greater participant experience as academic authors improved the ability to detect discrepancies. Results: Overall, 95.3% of discrepancies were missed. Most participants (62%) were unable to find any discrepancies. Only 11.5% noticed more than 10% of the discrepancies. More discrepancies were noted by participants who spent more time on the task (Spearman’s ρ = 0.22, P < 0.01), and those with more experience of publishing papers (Spearman’s ρ = 0.13 with number of publications, P = 0.04). Conclusions: Noticing discrepancies is difficult. Most readers miss most discrepancies even when asked specifically to look for them. The probability of a discrepancy evading an individual sensitized reader is 95%, making it important that, when problems are identified after publication, readers are able to communicate with each other. When made aware of discrepancies, the majority of readers support editorial action to correct the scientific record.
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Affiliation(s)
| | | | | | - Kevin G Buell
- School of Medicine, Imperial College London, London, UK
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104
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Karmali S, Mistry R, Walker D. To beta-block or not? Br J Hosp Med (Lond) 2015; 76:370. [PMID: 26053915 DOI: 10.12968/hmed.2015.76.6.370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Shamir Karmali
- Anaesthetic Trainee in the Central School of Anaesthesia, University College London Hospital NHS Trust, London NW1 2BU
| | - Ravin Mistry
- Anaesthetic Registrar and Research Fellow in Perioperative Medicine in the Department of Anaesthesia, University College London Hospital NHS Trust, London NW1 2BU
| | - David Walker
- Consultant Anaesthetist and Intensivist in the Department of Anaesthesia and Intensive Care, University College London Hospital NHS Trust, London NW1 2BU
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105
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Henig O, Avni T, Herndon DN, Finnerty CC, Leibovici L, Paul M. Beta adrenergic antagonists for hospitalized burned patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Oryan Henig
- Carmel Medical Centre; Infectious Disease Unit; Michal 7 Haifa Israel
| | - Tomer Avni
- Beilinson Hospital, Rabin Medical Center; Petah Tikva Israel
- Tel Aviv University; Sackler Faculty of Medicine; Tel Aviv Israel
| | - David N Herndon
- Shriners Hospitals for Children - Galveston; 815 Market Street Galveston TX USA 77550
| | - Celeste C Finnerty
- Shriners Hospitals for Children - Galveston; 815 Market Street Galveston TX USA 77550
- University of Texas Medical Branch; Department of Surgery; Galveston TX USA 77550
| | - Leonard Leibovici
- Beilinson Hospital, Rabin Medical Center; Department of Medicine E; Kaplan Street Petah Tikva Israel 49100
| | - Mical Paul
- Rambam Health Care Campus; Division of Infectious Diseases; Ha-aliya 8 St Haifa Israel 33705
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106
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Bensley RP, Beck AW. Using the Vascular Quality Initiative to improve quality of care and patient outcomes for vascular surgery patients. Semin Vasc Surg 2015; 28:97-102. [DOI: 10.1053/j.semvascsurg.2015.09.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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107
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Sear JW, Higham H, Foex P. Beta-blockade and other perioperative pharmacological protectors: what is now available and efficacious? Br J Anaesth 2015; 115:333-6. [PMID: 25991757 DOI: 10.1093/bja/aev146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- J W Sear
- Nuffield Division of Anaesthetics, University of Oxford, John Radcliffe Hospital, OXFORD OX3 9DU, UK
| | - H Higham
- Nuffield Division of Anaesthetics, University of Oxford, John Radcliffe Hospital, OXFORD OX3 9DU, UK
| | - P Foex
- Nuffield Division of Anaesthetics, University of Oxford, John Radcliffe Hospital, OXFORD OX3 9DU, UK
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108
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Jha S. Point: Twin Dogmas of Maintenance of Certification. J Am Coll Radiol 2015; 12:430-3. [DOI: 10.1016/j.jacr.2014.10.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 10/10/2014] [Accepted: 10/20/2014] [Indexed: 11/29/2022]
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109
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Illuminati G, Schneider F, Greco C, Mangieri E, Schiariti M, Tanzilli G, Barillà F, Paravati V, Pizzardi G, Calio’ F, Miraldi F, Macrina F, Totaro M, Greco E, Mazzesi G, Tritapepe L, Toscano M, Vietri F, Meyer N, Ricco JB. Long-term Results of a Randomized Controlled Trial Analyzing the Role of Systematic Pre-operative Coronary Angiography before Elective Carotid Endarterectomy in Patients with Asymptomatic Coronary Artery Disease. Eur J Vasc Endovasc Surg 2015; 49:366-74. [DOI: 10.1016/j.ejvs.2014.12.030] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2014] [Accepted: 12/22/2014] [Indexed: 11/28/2022]
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110
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[Catecholamines: pro and contra]. Med Klin Intensivmed Notfmed 2015; 111:37-46. [PMID: 25804726 DOI: 10.1007/s00063-015-0011-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 11/28/2014] [Accepted: 12/18/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Catecholamines with vasopressor and inotropic effects are commonly used in intensive care medicine. The aim of this review is to explain some of the physiologic actions on which a catecholamine therapy is based, but also to elucidate the risks which are associated with an uncritical and excessive use of these drugs. SIDE EFFECTS Emphasis is placed on the myocardial damage triggered by adrenergic overstimulation. There is considerable evidence that in conditions of severe heart failure, myocardial ischemia as well as cardiogenic and septic shock especially the use of catecholamines with predominant β-adrenergic effects (epinephrine, dobutamine, dopamine) can have a negative clinical impact. A simple cardiac risk marker might be a tachycardia. ADMINISTRATION Vasopressor therapy with norepinephrine, based on individually applied perfusion parameters (e.g., urine output, lactate), however, seems justified in many conditions of shock and hemodynamic instability during deep analgosedation. In terms of a cardioprotective therapy, the administration of catecholamines, however, should always be reevaluated and titrated to the minimum deemed necessary.
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111
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Kotecha D, von Lueder TG. Qualifying the use of common cardiovascular drugs in cardiology. Circ J 2015; 79:517-8. [PMID: 25746532 DOI: 10.1253/circj.cj-15-0088] [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: 11/09/2022]
Affiliation(s)
- Dipak Kotecha
- Centre for Cardiovascular Sciences, The Medical School, University of Birmingham; Monash Centre of Cardiovascular Research & Education in Therapeutics, Monash University, Melbourne, Victoria
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112
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Cegarra-Sanmartin V, Paniagua-Iglesias P, Popova E, de Nadal Clanchet M, Alonso-Coello P, Plou P, Mata Mena E, Fernández-Riveira C, García del Valle S, Tena Blanco B, Sabaté Tenas S, Font Gual A, Maestre Hittinger ML, González Rodríguez R. [Perioperative acetylsalicylic acid and clonidine in noncardiac surgery patients (POISE-2 trial)]. ACTA ACUST UNITED AC 2015; 62:270-4. [PMID: 25700958 DOI: 10.1016/j.redar.2014.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 12/10/2014] [Accepted: 12/11/2014] [Indexed: 11/27/2022]
Affiliation(s)
- V Cegarra-Sanmartin
- Departamento de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España.
| | - P Paniagua-Iglesias
- Departamento de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - E Popova
- Centro Cochrane Iberoamericano, Servicio de Epidemiología Clínica y Salud Pública, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - M de Nadal Clanchet
- Departamento de Anestesiología y Reanimación, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - P Alonso-Coello
- Centro Cochrane Iberoamericano, Servicio de Epidemiología Clínica y Salud Pública, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - P Plou
- Departamento de Anestesiología y Reanimación, Hospital Universitario de Donostia, San Sebastián, España
| | - E Mata Mena
- Departamento de Anestesiología y Reanimación, Hospital Universitario de La Princesa, Madrid, España
| | - C Fernández-Riveira
- Departamento de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - S García del Valle
- Departamento de Anestesiología y Reanimación, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - B Tena Blanco
- Departamento de Anestesiología y Reanimación, Hospital Clínic, Barcelona, España
| | - S Sabaté Tenas
- Departamento de Anestesiología y Reanimación, Fundación Puigvert, Barcelona, España
| | - A Font Gual
- Departamento de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - M L Maestre Hittinger
- Departamento de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - R González Rodríguez
- Departamento de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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113
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Iqbal J, Zhang YJ, Holmes DR, Morice MC, Mack MJ, Kappetein AP, Feldman T, Stahle E, Escaned J, Banning AP, Gunn JP, Colombo A, Steyerberg EW, Mohr FW, Serruys PW. Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: insights from the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial at the 5-year follow-up. Circulation 2015; 131:1269-77. [PMID: 25847979 DOI: 10.1161/circulationaha.114.013042] [Citation(s) in RCA: 150] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 01/26/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND There is a paucity of data on the use of optimal medical therapy (OMT) in patients with complex coronary artery disease undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting (CABG) and its long-term prognostic significance. METHODS AND RESULTS The Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX) trial is a multicenter, randomized, clinical trial of patients (n=1800) with complex coronary disease randomized to revascularization with percutaneous coronary intervention or CABG. Detailed drug history was collected for all patients at discharge and at the 1-month, 6-month, 1-year, 3-year, and 5-year follow-ups. OMT was defined as the combination of at least 1 antiplatelet drug, statin, β-blocker, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Five-year clinical outcomes were stratified by OMT and non-OMT. OMT was underused in patients treated with coronary revascularization, especially CABG. OMT was an independent predictor of survival. OMT was associated with a significant reduction in mortality (hazard ratio, 0.64; 95% confidence interval, 0.48-0.85; P=0.002) and composite end point of death/myocardial infarction/stroke (hazard ratio, 0.73; 95% confidence interval, 0.58-0.92; P=0.007) at the 5-year follow-up. The treatment effect with OMT (36% relative reduction in mortality over 5 years) was greater than the treatment effect of revascularization strategy (26% relative reduction in mortality with CABG versus percutaneous coronary intervention over 5 years). On stratified analysis, all the components of OMT were important for reducing adverse outcomes regardless of revascularization strategy. CONCLUSIONS The use of OMT remains low in patients with complex coronary disease requiring coronary intervention with percutaneous coronary intervention and even lower in patients treated with CABG. Lack of OMT is associated with adverse clinical outcomes. Targeted strategies to improve OMT use in postrevascularization patients are warranted. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00114972.
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Affiliation(s)
- Javaid Iqbal
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Yao-Jun Zhang
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - David R Holmes
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Marie-Claude Morice
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Michael J Mack
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Arie Pieter Kappetein
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Ted Feldman
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Elizabeth Stahle
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Javier Escaned
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Adrian P Banning
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Julian P Gunn
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Antonio Colombo
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Ewout W Steyerberg
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Friedrich W Mohr
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.)
| | - Patrick W Serruys
- From the Thoraxcenter (J.I., Y.-J.Z., A.P.K., P.W.S.) and Department of Public Health (E.W.S.), Erasmus Medical Centre, Rotterdam, The Netherlands; University of Sheffield, UK (J.I., J.P.G.); Mayo Clinic, Rochester, MN (D.R.H.); ICPS, Hopital privé Jacques Cartier, Générale de Santé Massy, France (M.-C.M.); The Heart Hospital, Dallas, TX (M.J.M.); Evanston Hospital, IL (T.F.); University Hospital Uppsala, Sweden (E.S.); Hospital Clínico San Carlos, Madrid, Spain (J.E.); Oxford University Hospitals, UK (A.P.B.); San Raffaele Scientific Institute, Milan, Italy (A.C.); Herzzentrum Universität Leipzig, Germany (F.W.M.); and International Centre for Circulatory Health, Imperial College London, UK (P.W.S.).
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114
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West MA, Parry M, Asher R, Key A, Walker P, Loughney L, Pintus S, Duffy N, Jack S, Torella F. The Effect of beta-blockade on objectively measured physical fitness in patients with abdominal aortic aneurysms--A blinded interventional study. Br J Anaesth 2015; 114:878-85. [PMID: 25716221 DOI: 10.1093/bja/aev026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Perioperative beta-blockade is widely used, especially before vascular surgery; however, its impact on exercise performance assessed using cardiopulmonary exercise testing (CPET) in this group is unknown. We hypothesized that beta-blocker therapy would significantly improve CPET-derived physical fitness in this group. METHODS We recruited patients with abdominal aortic aneurysms (AAA) of <5.5 cm under surveillance. All patients underwent CPET on and off beta-blockers. Patients routinely prescribed beta-blockers underwent a first CPET on medication. Beta-blockers were stopped for one week before a second CPET. Patients not routinely taking beta-blockers underwent the first CPET off treatment, then performed a second CPET after commencement of bisoprolol for at least 48 h. Oxygen uptake (.VO2) at estimated lactate threshold and .VO2 at peak were primary outcome variables. A linear mixed-effects model was fitted to investigate any difference in adjusted CPET variables on and off beta-blockers. RESULTS Forty-eight patients completed the study. No difference was observed in .VO2 at estimated lactate threshold and .VO2 at peak; however, a significant decrease in .VE/.VCO2 at estimated lactate threshold and peak, an increase in workload at estimated lactate threshold., O2 pulse and heart rate both at estimated lactate threshold and peak was found with beta-blockers. Patients taking beta-blockers routinely (chronic group) had worse exercise performance (lower .VO2 ). CONCLUSIONS Beta blockade has a significant impact on CPET-derived exercise performance, albeit without changing .VO2 at estimated lactate threshold and.VO2 at peak. This supports performance of preoperative CPET on or off beta-blockers depending on local perioperative practice. CLINICAL TRIAL REGISTRATION NCT 02106286.
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Affiliation(s)
- M A West
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
| | - M Parry
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - R Asher
- Cancer Research UK Liverpool Cancer Trials Unit, Waterhouse Building, University of Liverpool, Liverpool, UK
| | - A Key
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - P Walker
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
| | - L Loughney
- Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
| | - S Pintus
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building
| | - N Duffy
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building
| | - S Jack
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Respiratory Research Group, 3rd Floor Clinical Sciences Building Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and Anaesthesia and Critical Care Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Road, Southampton, UK
| | - F Torella
- Perioperative CPET Research Group, 3rd Floor Clinical Sciences Building Liverpool Vascular & Endovascular Service, Aintree University Hospitals NHS Foundation Trust, Lower Lane, Liverpool, UK Department of Musculoskeletal Biology, Faculty of Health and Life Sciences and
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115
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Alper BS, Fedorowicz Z, Strite SA, Stuart ME, Shaughnessy AF. Evolution of evidence-based medicine to detect evidence mutations. Med Chir Trans 2015; 108:8-10. [DOI: 10.1177/0141076814555936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Zbys Fedorowicz
- The Bahrain Branch, The Cochrane Collaboration, Manama 25438, Bahrain
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Abstract
Because most older adults with hip fractures require urgent surgical intervention, the preoperative medical evaluation focuses on the exclusion of the small number of contraindications to surgery, and rapid optimization of patients for operative repair. Although many geriatric fracture patients have significant chronic medical comorbidities, most patients can be safely stabilized for surgery with medical and orthopedic comanagement by anticipating a small number of common physiologic responses and perioperative complications. In addition to estimating perioperative risk, the team should focus on intravascular volume restoration, pain control, and avoidance of perioperative hypotension.
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Affiliation(s)
- Joseph A Nicholas
- Division of Geriatrics, Highland Hospital, University of Rochester School of Medicine, 1000 South Avenue, Box 58, Rochester, NY 14610, USA.
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118
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Slawski BA, Cohn SL, Pfeifer KJ, Dutta S, Jaffer AK, Smetana GW. Perioperative cardiovascular medicine: an update of the literature 2013-2014. Hosp Pract (1995) 2014; 42:126-34. [PMID: 25502136 DOI: 10.3810/hp.2014.10.1149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Perioperative medicine is an important and rapidly expanding area of interest across multiple specialties, including internal medicine, anesthesiology, surgery, cardiology, and hospital medicine. A multispecialty team approach that ensures the best possible patient outcomes has fostered collaborative strategies across the continuum of patient care. Staying current in this multidisciplinary field is difficult, because physicians interested in perioperative medicine would need to review multiple specialty journals on a regular basis. To facilitate this process, the authors performed a focused review of this literature published in 2013 and early 2014. In this update, key articles are reviewed that potentially impact clinical practice in perioperative cardiovascular risk prediction and risk management.
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Affiliation(s)
- Barbara A Slawski
- Medical College of Wisconsin, Froedtert Memorial Lutheran Hospital Clinical Cancer Center, Milwaukee, WI
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119
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:e77-137. [PMID: 25091544 DOI: 10.1016/j.jacc.2014.07.944] [Citation(s) in RCA: 813] [Impact Index Per Article: 81.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
Perioperative β-blocker therapy has been advocated to reduce cardiac mortality and morbidity in high-risk cardiac patients undergoing non-cardiac surgery. Core data that supported this intervention and informed international societal guidelines has recently been withdrawn. A subsequent meta-analysis of the remaining data reporting excess mortality has re-opened the debate about the utility of β-blocker therapy in the perioperative period. Criticism of remaining trial designs and new insights into the protective mechanisms of β-blocker therapy in critical illness raise important questions that should now be addressed by a further robust, high-quality randomised control trial.
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Affiliation(s)
- Ravin Mistry
- Anaesthetics Department, University College Hospital NHS Foundation Trust, London, UK
| | - David Walker
- Anaesthetics Department, University College Hospital NHS Foundation Trust, London, UK
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121
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Grupo de Trabajo Conjunto sobre cirugía no cardiaca: Evaluación y manejo cardiovascular de la Sociedad Europea de Cardiología (ESC) y la European Society of Anesthesiology (ESA). Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2014.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Neuman MD, Bosk CL, Fleisher LA. Learning from mistakes in clinical practice guidelines: the case of perioperative β-blockade. BMJ Qual Saf 2014; 23:957-64. [PMID: 25136141 PMCID: PMC4348068 DOI: 10.1136/bmjqs-2014-003114] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
For more than two decades, the role of beta-blockers in preventing cardiac complications after major surgery has been the subject of contentious scientific and policy debate. Based on two small but highly publicized randomized trials published in 1996 and 1999, prominent U.S. organizations embraced preoperative beta-blocker initiation as a “best practice” and an opportunity for widespread safety improvement. Yet only a few years later, expert recommendations regarding preoperative beta-blockers were revised and downgraded when subsequent research failed confirm promising early findings and called attention to potential harms associated with beta-blocker overuse. In this paper, we trace the history of preoperative beta-blocker recommendations as a case study in lessons to be learned from reversals of guideline recommendations based initially on evidence drawn from randomized, controlled trials. Ultimately, we find that the policy significance that stakeholders ascribed to early beta-blocker studies combined with the prestige that experts assigned to the randomized controlled trial as a form of evidence to short-circuit discourse on the risks of preoperative beta-blocker initiation and led it to be elevated prematurely as a best practice. As such, the story of preoperative beta-blockers illustrates threats to objectivity in guidelines that can emerge from policy imperatives that lend primacy to the rapid translation of research into practice and from perspectives that unduly emphasize the strengths of randomized trials.
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Affiliation(s)
- Mark D. Neuman
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania
- The Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Charles L. Bosk
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania
- The Leonard Davis Institute of Health Economics, University of Pennsylvania
- Department of Sociology, University of Pennsylvania
| | - Lee A. Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania
- The Leonard Davis Institute of Health Economics, University of Pennsylvania
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Affiliation(s)
- E E van der Wall
- Interuniversity Cardiology Institute of the Netherlands (ICIN) - Netherlands Heart Institute (NHI), P.O. Box 19258, 3501 DG, Utrecht, the Netherlands,
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Kinugawa H, Shimada Y. A case of above knee amputation with preoperative high risks. J Rural Med 2014; 9:90-2. [PMID: 25648570 PMCID: PMC4310149 DOI: 10.2185/jrm.2888] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 08/19/2014] [Indexed: 11/27/2022] Open
Abstract
An 85-year-old malnourished man was admitted with ischemia-induced necrosis of the right
leg and high-risk factors, including chronic obstructive pulmonary disease, pneumonia, and
infection of the necrotic leg. We controlled the infection and provided proper nutrition.
Using light general anesthesia and a nerve block, we amputated the leg above the knee. The
patient could eat and drink the same day following the surgery, and respiratory
rehabilitation was begun the next day. His postoperative course was uneventful. Our case
suggests that maintenance of good nutrition may play a key role for high-risk elders
undergoing leg amputation.
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Affiliation(s)
- Hiroki Kinugawa
- Department of Cardiovascular Surgery, Yuri-Kumiai General Hospital, Japan
| | - Yasuyuki Shimada
- Department of Cardiovascular Surgery, Yuri-Kumiai General Hospital, Japan
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Kones R, Rumana U, Merino J. Exclusion of 'nonRCT evidence' in guidelines for chronic diseases - is it always appropriate? The Look AHEAD study. Curr Med Res Opin 2014; 30:2009-19. [PMID: 24841173 DOI: 10.1185/03007995.2014.925438] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Evidence-based medicine (EBM) is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The introduction of EBM was a conceptual and practical milestone in the history of medicine, with far-reaching impact yet to be fully realized. EBM has limitations, including inapplicability to populations dissimilar to those in studies, and may not reflect duration of exposure to risk factors, details of lifestyle, incubation period, latency, or environmental changes during chronic diseases. Routine exclusion of evidence other than randomized controlled trials (RCTs) or meta-analyses from consideration in treatment may not always be wise. This review is not a result of a search, but rather a conceptual unification of (a) the increasing restrictions in guideline-writing favoring more RCTs, and rejecting observational studies when chronic diseases with a long incubation period may sometimes be best probed by the latter; (b) the possibility RCTs may be inconclusive, nonapplicable, or result in 'negative' results which may misdirect future therapy by physicians and undermine adherence by patients; (c) the potential improvement in patient care from having all available information evaluated (especially epidemiological studies of chronic diseases) and synthesized in guidelines. The example of the Look AHEAD study is chosen - a 'negative' RCT with significant information overlooked by reviewers, who initially declared that weight loss and physical activity were ineffective in treating diabetes, or in preventing cardiovascular complications. In this review, placing this study in perspective, among others, suggests the opposite - exercise and weight loss are effective if done early and sufficiently. Synthesizing worthy data from many sources, including prospective and pathophysiological studies, particularly when RCTs are unavailable, has the potential to add depth and expand the understanding of disease. In addition, integrated data may generate useful, rich material for use during shared decision making discussions with patients, and clarify future hypotheses.
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Affiliation(s)
- Richard Kones
- Cardiometabolic Research Institute , Houston, TX , USA
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Wan YD, Zhang SG, Sun TW, Kan QC, Wang LX. The effects of perioperative β-blockers on mortality in patients undergoing non-cardiac surgery in real world: A meta-analysis of cohort studies. Int J Cardiol 2014; 176:605-10. [DOI: 10.1016/j.ijcard.2014.07.073] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 07/24/2014] [Indexed: 10/24/2022]
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Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, De Hert S, Ford I, Juanatey JRG, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Luescher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Uva MS, Voudris V, Funck-Brentano C. 2014 ESC/ESA Guidelines on non-cardiac surgery. Eur J Anaesthesiol 2014; 31:517-73. [DOI: 10.1097/eja.0000000000000150] [Citation(s) in RCA: 286] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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129
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Paniagua Iglesias P, Díaz Ruano S, Álvarez-García J. Lesión miocárdica tras la cirugía no cardiaca. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2014.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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130
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2014 European Society of Cardiology/European Society of Anaesthesiology guidelines on non-cardiac surgery. Eur J Anaesthesiol 2014; 31:513-6. [DOI: 10.1097/eja.0000000000000155] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Blessberger H, Kammler J, Domanovits H, Schlager O, Wildner B, Azar D, Schillinger M, Wiesbauer F, Steinwender C. Perioperative beta-blockers for preventing surgery-related mortality and morbidity. Cochrane Database Syst Rev 2014:CD004476. [PMID: 25233038 DOI: 10.1002/14651858.cd004476.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Randomized controlled trials have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in unselected patients remains a controversial issue. OBJECTIVES The objective of this review was to systematically analyse the effects of perioperatively administered beta-blockers for prevention of surgery-related mortality and morbidity in patients undergoing any type of surgery while under general anaesthesia. SEARCH METHODS We identified trials by searching the following databases from the date of their inception until June 2013: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Biosis Previews, CAB Abstracts, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Derwent Drug File, Science Citation Index Expanded, Life Sciences Collection, Global Health and PASCAL. In addition, we searched online resources to identify grey literature. SELECTION CRITERIA We included randomized controlled trials if participants were randomly assigned to a beta-blocker group or a control group (standard care or placebo). Surgery (any type) had to be performed with all or at least a significant proportion of participants under general anaesthesia. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from all studies. In cases of disagreement, we reassessed the respective studies to reach consensus. We computed summary estimates in the absence of significant clinical heterogeneity. Risk ratios (RRs) were used for dichotomous outcomes, and mean differences (MDs) were used for continuous outcomes. We performed subgroup analyses for various potential effect modifiers. MAIN RESULTS We included 89 randomized controlled trials with 19,211 participants. Six studies (7%) met the highest methodological quality criteria (studies with overall low risk of bias: adequate sequence generation, adequate allocation concealment, double/triple-blinded design with a placebo group, intention-to-treat analysis), whereas in the remaining trials, some form of bias was present or could not be definitively excluded (studies with overall unclear or high risk of bias). Outcomes were evaluated separately for cardiac and non-cardiac surgery. CARDIAC SURGERY (53 trials)We found no clear evidence of an effect of beta-blockers on the following outcomes.• All-cause mortality: RR 0.73, 95% CI 0.35 to 1.52, 3783 participants, moderate quality of evidence.• Acute myocardial infarction (AMI): RR 1.04, 95% CI 0.71 to 1.51, 3553 participants, moderate quality of evidence.• Myocardial ischaemia: RR 0.51, 95% CI 0.25 to 1.05, 166 participants, low quality of evidence.• Cerebrovascular events: RR 1.52, 95% CI 0.58 to 4.02, 1400 participants, low quality of evidence.• Hypotension: RR 1.54, 95% CI 0.67 to 3.51, 558 participants, low quality of evidence.• Bradycardia: RR 1.61, 95% CI 0.97 to 2.66, 660 participants, low quality of evidence.• Congestive heart failure: RR 0.22, 95% CI 0.04 to 1.34, 311 participants, low quality of evidence.Beta-blockers significantly reduced the occurrence of the following endpoints.• Ventricular arrhythmias: RR 0.37, 95% CI 0.24 to 0.58, number needed to treat for an additional beneficial outcome (NNTB) 29, 2292 participants, moderate quality of evidence.• Supraventricular arrhythmias: RR 0.44, 95% CI 0.36 to 0.53, NNTB six, 6420 participants, high quality of evidence.• On average, beta-blockers reduced length of hospital stay by 0.54 days (95% CI -0.90 to -0.19, 2450 participants, low quality of evidence). NON-CARDIAC SURGERY (36 trials)We found a potential increase in the occurrence of the following outcomes with the use of beta-blockers.• All-cause mortality: RR 1.24, 95% CI 0.99 to 1.54, 11,463 participants, low quality of evidence.Whereas no clear evidence of an effect was noted when all studies were analysed, restricting the meta-analysis to low risk of bias studies revealed a significant increase in all-cause mortality with the use of beta-blockers: RR 1.27, 95% CI 1.01 to 1.59, number needed to treat for an additional harmful outcome (NNTH) 189, 10,845 participants.• Cerebrovascular events: RR 1.59, 95% CI 0.93 to 2.71, 9150 participants, low quality of evidence.Whereas no clear evidence of an effect was found when all studies were analysed, restricting the meta-analysis to low risk of bias studies revealed a significant increase in cerebrovascular events with the use of beta-blockers: RR 2.09, 95% CI 1.14 to 3.82, NNTH 255, 8648 participants.Beta-blockers significantly reduced the occurrence of the following endpoints.• AMI: RR 0.73, 95% CI 0.61 to 0.87, NNTB 72, 10,958 participants, high quality of evidence.• Myocardial ischaemia: RR 0.43, 95% CI 0.27 to 0.70, NNTB seven, 1028 participants, moderate quality of evidence.• Supraventricular arrhythmias: RR 0.72, 95% CI 0.56 to 0.92, NNTB 111, 8794 participants, high quality of evidence.Beta-blockers significantly increased the occurrence of the following adverse events.• Hypotension: RR 1.50, 95% CI 1.38 to 1.64, NNTH 15, 10,947 participants, high quality of evidence.• Bradycardia: RR 2.24, 95% CI 1.49 to 3.35, NNTH 18, 11,083 participants, moderate quality of evidence.We found no clear evidence of an effect of beta-blockers on the following outcomes.• Ventricular arrhythmias: RR 0.64, 95% CI 0.30 to 1.33, 526 participants, moderate quality of evidence.• Congestive heart failure: RR 1.17, 95% CI 0.93 to 1.47, 9223 participants, moderate quality of evidence.• Length of hospital stay: mean difference -0.27 days, 95% CI -1.29 to 0.75, 601 participants, low quality of evidence. AUTHORS' CONCLUSIONS According to our findings, perioperative application of beta-blockers still plays a pivotal role in cardiac surgery , as they can substantially reduce the high burden of supraventricular and ventricular arrhythmias in the aftermath of surgery. Their influence on mortality, AMI, stroke, congestive heart failure, hypotension and bradycardia in this setting remains unclear.In non-cardiac surgery, evidence from low risk of bias trials shows an increase in all-cause mortality and stroke with the use of beta-blockers. As the quality of evidence is still low to moderate, more evidence is needed before a definitive conclusion can be drawn. The substantial reduction in supraventricular arrhythmias and AMI in this setting seems to be offset by the potential increase in mortality and stroke.
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Affiliation(s)
- Hermann Blessberger
- Department of Internal Medicine I - Cardiology, Linz General Hospital (Allgemeines Krankenhaus Linz) Johannes Kepler University School of Medicine, Krankenhausstraße 9, Linz, Austria, 4020
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Myocardial injury after noncardiac surgery. ACTA ACUST UNITED AC 2014; 67:794-6. [PMID: 25205649 DOI: 10.1016/j.rec.2014.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 05/26/2014] [Indexed: 11/21/2022]
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Wijeysundera DN, Duncan D, Nkonde-Price C, Virani SS, Washam JB, Fleischmann KE, Fleisher LA. Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2246-64. [PMID: 25085964 DOI: 10.1161/cir.0000000000000104] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates. METHODS PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions. RESULTS We identified 17 studies, of which 16 were RCTs (12 043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI: 1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR: 0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded. CONCLUSIONS Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.
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Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, Davila-Roman VG, Gerhard-Herman MD, Holly TA, Kane GC, Marine JE, Nelson MT, Spencer CC, Thompson A, Ting HH, Uretsky BF, Wijeysundera DN. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:e278-333. [PMID: 25085961 DOI: 10.1161/cir.0000000000000106] [Citation(s) in RCA: 209] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Kristensen SD, Knuuti J, Saraste A, Anker S, Bøtker HE, Hert SD, Ford I, Gonzalez-Juanatey JR, Gorenek B, Heyndrickx GR, Hoeft A, Huber K, Iung B, Kjeldsen KP, Longrois D, Lüscher TF, Pierard L, Pocock S, Price S, Roffi M, Sirnes PA, Sousa-Uva M, Voudris V, Funck-Brentano C. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35:2383-431. [PMID: 25086026 DOI: 10.1093/eurheartj/ehu282] [Citation(s) in RCA: 808] [Impact Index Per Article: 80.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Perioperative beta blockade in noncardiac surgery: a systematic review for the 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol 2014; 64:2406-25. [PMID: 25091545 DOI: 10.1016/j.jacc.2014.07.939] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the literature systematically to determine whether initiation of beta blockade within 45 days prior to noncardiac surgery reduces 30-day cardiovascular morbidity and mortality rates. METHODS PubMed (up to April 2013), Embase (up to April 2013), Cochrane Central Register of Controlled Trials (up to March 2013), and conference abstracts (January 2011 to April 2013) were searched for randomized controlled trials (RCTs) and cohort studies comparing perioperative beta blockade with inactive control during noncardiac surgery. Pooled relative risks (RRs) were calculated under the random-effects model. We conducted subgroup analyses to assess how the DECREASE-I (Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography), DECREASE-IV, and POISE-1 (Perioperative Ischemic Evaluation) trials influenced our conclusions. RESULTS We identified 17 studies, of which 16 were RCTs (12,043 participants) and 1 was a cohort study (348 participants). Aside from the DECREASE trials, all other RCTs initiated beta blockade within 1 day or less prior to surgery. Among RCTs, beta blockade decreased nonfatal myocardial infarction (MI) (RR: 0.69; 95% confidence interval [CI]: 0.58 to 0.82) but increased nonfatal stroke (RR: 1.76; 95% CI:1.07 to 2.91), hypotension (RR: 1.47; 95% CI: 1.34 to 1.60), and bradycardia (RR: 2.61; 95% CI: 2.18 to 3.12). These findings were qualitatively unchanged after the DECREASE and POISE-1 trials were excluded. Effects on mortality rate differed significantly between the DECREASE trials and other trials. Beta blockers were associated with a trend toward reduced all-cause mortality rate in the DECREASE trials (RR: 0.42; 95% CI: 0.15 to 1.22) but with increased all-cause mortality rate in other trials (RR: 1.30; 95% CI: 1.03 to 1.64). Beta blockers reduced cardiovascular mortality rate in the DECREASE trials (RR:0.17; 95% CI: 0.05 to 0.64) but were associated with trends toward increased cardiovascular mortality rate in other trials (RR: 1.25; 95% CI: 0.92 to 1.71). These differences were qualitatively unchanged after the POISE-1 trial was excluded. CONCLUSIONS Perioperative beta blockade started within 1 day or less before noncardiac surgery prevents nonfatal MI but increases risks of stroke, death, hypotension, and bradycardia. Without the controversial DECREASE studies, there are insufficient data on beta blockade started 2 or more days prior to surgery. Multicenter RCTs are needed to address this knowledge gap.
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Mounsey A, Roque JM, Egan M. PURLs: Why you shouldn't start beta-blockers before surgery. THE JOURNAL OF FAMILY PRACTICE 2014; 63:E15-E16. [PMID: 25061626 PMCID: PMC4140109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
A new meta-analysis finds that initiating beta-blockers before surgery increases patients' risk of death.
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Affiliation(s)
- Anne Mounsey
- Department of Family Medicine, University of North Carolina Chapel Hill, NC, USA
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Nicholas JA. Management of postoperative complications: cardiovascular disease and volume management. Clin Geriatr Med 2014; 30:293-301. [PMID: 24721369 DOI: 10.1016/j.cger.2014.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Postoperative cardiovascular complications are common, predictable, and typically treatable in geriatric patients who have sustained fractures. Although intervention-specific data are sparse, observational evidence from high-performing geriatric fracture centers coupled with an understanding of geriatric principles can serve as a basis for treatment guidelines. Many patients can be safely and effectively managed with close attention to intravascular volume status, heart rate control, and minimization of other physiologic stresses, including pain and delirium. Many chronic cardiovascular therapies may be harmful in the immediate postoperative period, and can usually be safely omitted or attenuated until hemodynamic stability and mobility have been restored.
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Affiliation(s)
- Joseph A Nicholas
- Division of Geriatrics, Highland Hospital, University of Rochester School of Medicine, 1000 South Avenue Box 58, Rochester, NY 14610, USA.
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Vaishnava P, Eagle KA. β-blockade to prevent perioperative death in non-cardiac surgery: questions, controversy, and not enough answers. Heart 2014; 100:443-4. [PMID: 24553256 DOI: 10.1136/heartjnl-2013-305384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Prashant Vaishnava
- The Department of Internal Medicine, The Division of Cardiovascular Medicine, The University of Michigan Health System, , Ann Arbor, Michigan, , USA
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Kim TY. Perioperative adrenergic response and the use of beta-blockers. Korean J Anesthesiol 2014; 67:161-3. [PMID: 25302091 PMCID: PMC4188759 DOI: 10.4097/kjae.2014.67.3.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Tae-Yop Kim
- Department of Anesthesiology and Pain Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
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