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Sayyed R, Alam MB. Perioperative Cardiac Considerations in the Surgical Patient. Clin Podiatr Med Surg 2019; 36:103-113. [PMID: 30446038 DOI: 10.1016/j.cpm.2018.09.001] [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: 10/28/2022]
Abstract
The ability to identify and guide evaluation of the patient with cardiac disease represents a necessary skill for success in surgery of the foot and ankle. Common risk factors, such as diabetes and peripheral arterial disease, are encountered in podiatric practice. Recognition of patients at risk for cardiac disease and a predilection for sustaining a major adverse cardiac event perioperatively advocates for preoperative cardiology consultation. Identification of risk factors, assessment of functional capacity, and appropriate work-up mitigate any untoward cardiac events surrounding surgery. This optimization results from appropriate medical and interventional treatment plans directed at minimizing or eliminating identified risks factors.
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Affiliation(s)
- Rameez Sayyed
- Department of Adult Cardiovascular Medicine, Joan C. Edwards School of Medicine, Marshall University, 1249 15th Street, Suite 4000, Huntington, WV 25701, USA
| | - Mian Bilal Alam
- Department of Adult Cardiovascular Medicine, Joan C. Edwards School of Medicine, Marshall University, 1249 15th Street, Suite 4000, Huntington, WV 25701, USA.
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Xenon and Cardioprotection: Is This the Light at the End of the Tunnel? Anesthesiology 2017; 127:913-914. [PMID: 28872481 DOI: 10.1097/aln.0000000000001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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4
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Alonso-Coello P, Cook D, Xu SC, Sigamani A, Berwanger O, Sivakumaran S, Yang H, Xavier D, Martinez LX, Ibarra P, Rao-Melacini P, Pogue J, Zarnke K, Paniagua P, Ostrander J, Yusuf S, Devereaux PJ. Predictors, Prognosis, and Management of New Clinically Important Atrial Fibrillation After Noncardiac Surgery: A Prospective Cohort Study. Anesth Analg 2017. [DOI: 10.1213/ane.0000000000002111] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Rafiq A, Sklyar E, Bella JN. Cardiac Evaluation and Monitoring of Patients Undergoing Noncardiac Surgery. Health Serv Insights 2017; 9:1178632916686074. [PMID: 28469459 PMCID: PMC5398290 DOI: 10.1177/1178632916686074] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/24/2016] [Indexed: 12/25/2022] Open
Abstract
Surgical management of disease has a tremendous impact on our health system. Millions of people worldwide undergo surgeries every year. Cardiovascular complications in the perioperative period are one of the most common events leading to increased morbidity and mortality. Although such events are very small in number, they are associated with a high mortality rate making it essential for physicians to understand the importance of perioperative cardiovascular risk assessment and evaluation. Its involves a detailed process of history taking, patient's medical profile, medications being used, functional status of the patient, and knowledge about the surgical procedure and its inherent risks. Different risk assessment tools and calculators have also been developed to aid in this process, each with their own advantages and limitations. After such a comprehensive evaluation, a physician will be able to provide a risk assessment or it may all lead to further testing if it is believed that a change in management after such testing will help to reduce perioperative morbidity and mortality. There is extensive literature on the significance of multiple perioperative testing modalities and how they can change management. The purpose of our review is to provide a concise but comprehensive analysis on all such aspects of perioperative cardiovascular risk assessment for noncardiac surgeries and provide a basic methodology toward such assessment and decision making.
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Affiliation(s)
- Arsalan Rafiq
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eduard Sklyar
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jonathan N Bella
- Division of Cardiology, Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA
- Internal medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Karam D, Arora R. Perioperative β-Blockers in Patients Undergoing Noncardiac Surgery-Scientific Misconduct and Clinical Guidelines. Am J Ther 2017; 24:e435-e441. [PMID: 28092285 DOI: 10.1097/mjt.0000000000000548] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND β-blocker use in perioperative period of noncardiac surgeries has been a topic of debate since many years. Earlier studies conducted in the 90s showed decreased cardiac adverse events and improved postoperative outcomes with β-blocker use. Based on this, the ACCF and ESC published guidelines strongly supporting β-blocker use. But contemporaneous studies conducted revealed conflicting evidence and have also proven some of the earlier studies to be fraudulent. Although ACCF guidelines have been updated to partially reflect the changes, ESC guidelines continue to support β-blocker use. AREAS OF UNCERTAINTY In light of the ACCF and ESC guidelines supporting β-blocker use in perioperative period of noncardiac surgeries, our aim was to review the available literature and consolidate evidence in this regard. DATA SOURCES PubMed search was conducted to include relevant studies between 1950 and 2015. RESULTS We reviewed 24 eligible studies and few debates conducted in this regard. Based on our review, our findings were as follows: β-blockers should be continued throughout perioperative period in patients who were on β-blockers before surgery for other indications such as angina, hypertension, and symptomatic arrhythmias. Preoperative β-blockers are indicated in patients undergoing high risk vascular surgery or those having high preoperative Cardiac Risk Index Score. In patients with intermediate-to-low cardiac risk, the proven benefit is not sufficient enough to suggest universal use. CONCLUSIONS Based on our review, we conclude that the use of β-blockers in perioperative period of noncardiac surgeries should be determined on an individual basis based on risk-benefit analysis. Guideline organizations should update their recommendations based on new evidence.
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Affiliation(s)
- Dhauna Karam
- Department of Medicine, Chicago Medical School, North Chicago, IL
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Robertson L, Atallah E, Stansby G. Pharmacological treatment of vascular risk factors for reducing mortality and cardiovascular events in patients with abdominal aortic aneurysm. Cochrane Database Syst Rev 2017; 1:CD010447. [PMID: 28079254 PMCID: PMC6464734 DOI: 10.1002/14651858.cd010447.pub3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Pharmacological prophylaxis has been proven to reduce the risk of cardiovascular events in individuals with atherosclerotic occlusive arterial disease. However, the role of prophylaxis in individuals with abdominal aortic aneurysm (AAA) remains unclear. Several studies have shown that despite successful repair, those people with AAA have a poorer rate of survival than healthy controls. People with AAA have an increased prevalence of coronary heart disease and risk of cardiovascular events. Despite this association, little is known about the effectiveness of pharmacological prophylaxis in reducing cardiovascular risk in people with AAA. This is an update of a Cochrane review first published in 2014. OBJECTIVES To determine the long-term effectiveness of antiplatelet, antihypertensive or lipid-lowering medication in reducing mortality and cardiovascular events in people with abdominal aortic aneurysm (AAA). SEARCH METHODS For this update the Cochrane Vascular Information Specialist (CIS) searched the Cochrane Vascular Specialised Register (14 April 2016). In addition, the CIS searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 3) and trials registries (14 April 2016) and We also searched the reference lists of relevant articles. SELECTION CRITERIA Randomised controlled trials in which people with AAA were randomly allocated to one prophylactic treatment versus another, a different regimen of the same treatment, a placebo, or no treatment were eligible for inclusion in this review. Primary outcomes included all-cause mortality and cardiovascular mortality. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, and completed quality assessment and data extraction. We resolved any disagreements by discussion. Only one study met the inclusion criteria of the review, therefore we were unable to perform meta-analysis. MAIN RESULTS No new studies met the inclusion criteria for this update. We included one randomised controlled trial in the review. A subgroup of 227 participants with AAA received either metoprolol (N = 111) or placebo (N = 116). There was no clear evidence that metoprolol reduced all-cause mortality (odds ratio (OR) 0.17, 95% confidence interval (CI) 0.02 to 1.41), cardiovascular death (OR 0.20, 95% CI 0.02 to 1.76), AAA-related death (OR 1.05, 95% CI 0.06 to 16.92) or increased nonfatal cardiovascular events (OR 1.44, 95% CI 0.58 to 3.57) 30 days postoperatively. Furthermore, at six months postoperatively, estimated effects were compatible with benefit and harm for all-cause mortality (OR 0.71, 95% CI 0.26 to 1.95), cardiovascular death (OR 0.73, 95% CI 0.23 to 2.39) and nonfatal cardiovascular events (OR 1.41, 95% CI 0.59 to 3.35). Adverse drug effects were reported for the whole study population and were not available for the subgroup of participants with AAA. We considered the study to be at a generally low risk of bias. We downgraded the quality of the evidence for all outcomes to low. We downgraded the quality of evidence for imprecision as only one study with a small number of participants was available, the number of events was small and the result was consistent with benefit and harm. AUTHORS' CONCLUSIONS Due to the limited number of included trials, there is insufficient evidence to draw any conclusions about the effectiveness of cardiovascular prophylaxis in reducing mortality and cardiovascular events in people with AAA. Further good-quality randomised controlled trials that examine many types of prophylaxis with long-term follow-up are required before firm conclusions can be made.
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Affiliation(s)
- Lindsay Robertson
- Freeman HospitalDepartment of Vascular SurgeryNewcastle upon Tyne Hospitals NHS Foundation TrustHigh HeatonNewcastle upon TyneUKNE7 7DN
| | - Edmond Atallah
- United Lincolnshire Hospitals NHS TrustGastroenterologyGreetwell RoadLincolnEast MidlandsUKLN2 5QY
| | - Gerard Stansby
- Freeman HospitalNorthern Vascular CentreNewcastle upon TyneUKNE7 7DN
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Fraser K, Raju I. Anaesthesia for lower limb revascularization surgery. BJA Educ 2015. [DOI: 10.1093/bjaed/mku042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Developed in collaboration with the American College of Surgeons, American Society of Anesthesiologists, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Anesthesiologists, and Society of Vascular Medicine Endorsed by the Society of Hospital Medicine. J Nucl Cardiol 2015; 22:162-215. [PMID: 25523415 DOI: 10.1007/s12350-014-0025-z] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Mostafaie K, Bedenis R, Harrington D. Beta-adrenergic blockers for perioperative cardiac risk reduction in people undergoing vascular surgery. Cochrane Database Syst Rev 2015; 1:CD006342. [PMID: 25879091 PMCID: PMC10613805 DOI: 10.1002/14651858.cd006342.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND People undergoing major vascular surgery have an increased risk of postoperative cardiac complications. Beta-adrenergic blockers represent an important and established pharmacological intervention in the prevention of cardiac complications in people with coronary artery disease. It has been proposed that this class of drugs may reduce the risk of perioperative cardiac complications in people undergoing major non-cardiac vascular surgery. OBJECTIVES To review the efficacy and safety of perioperative beta-adrenergic blockade in reducing cardiac or all-cause mortality, myocardial infarction, and other cardiovascular safety outcomes in people undergoing major non-cardiac vascular surgery. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (January 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2013, Issue 12). We searched trials databases and checked reference lists of relevant articles. SELECTION CRITERIA We included prospective, randomised controlled trials of perioperative beta-adrenergic blockade of people over 18 years of age undergoing non-cardiac vascular surgery. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection and data extraction. We resolved disagreements through discussion. We performed meta-analysis using a fixed-effect model with odds ratios (ORs) and 95% confidence intervals (CIs). MAIN RESULTS We included two studies in this review, both of which were double-blind, randomised controlled trials comparing perioperative beta-adrenergic blockade (metoprolol) with placebo, on cardiovascular outcomes in people undergoing major non-cardiac vascular surgery. We included 599 participants receiving beta-adrenergic blockers (301 participants) or placebo (298 participants). The overall quality of studies was good. However, one study did not report random sequence generation or allocation concealment techniques, indicating possible selection bias, and the other study did not report outcome assessor blinding and was possibly underpowered. It should be noted that several of the outcomes were only reported in a single study and neither of the studies reported on vascular patency/graft occlusion, which reduces the quality of evidence to moderate. There was no evidence that perioperative beta-adrenergic blockade reduced all-cause mortality (OR 0.62, 95% CI 0.03 to 15.02), cardiovascular mortality (OR 0.34, 95% CI 0.01 to 8.32), non-fatal myocardial infarction (OR 0.83, 95% CI 0.46 to 1.49; P value = 0.53), arrhythmia (OR 0.70, 95% CI 0.26 to 1.88), heart failure (OR 1.71, 95% CI 0.40 to 7.23), stroke (OR 2.67, 95% CI 0.11 to 67.08), composite cardiovascular events (OR 0.87, 95% CI 0.55 to 1.39; P value = 0.57) or re-hospitalisation at 30 days (OR 0.86, 95% CI 0.48 to 1.52). However, there was strong evidence that beta-adrenergic blockers increased the odds of intra-operative bradycardia (OR 4.97, 95% CI 3.22 to 7.65; P value < 0.00001) and intra-operative hypotension (OR 1.84, 95% CI 1.31 to 2.59; P value = 0.0005). AUTHORS' CONCLUSIONS This meta-analysis currently offers no clear evidence that perioperative beta-adrenergic blockade reduces postoperative cardiac morbidity and mortality in people undergoing major non-cardiac vascular surgery. There is evidence that intra-operative bradycardia and hypotension are more likely in people taking perioperative beta-adrenergic blockers, which should be weighed with any benefit.
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Affiliation(s)
- Katayoun Mostafaie
- David Geffen School of Medicine at UCLADepartment of Medicine1000 West CarsonTorranceCaliforniaUSA92604
| | - Rachel Bedenis
- University of EdinburghCentre for Population Health SciencesEdinburghUKEH8 9AG
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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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2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery: Executive Summary. J Am Coll Cardiol 2014. [DOI: 10.1016/j.jacc.2014.07.945] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Schneider L, Farrokhyar F, Schieman C, Shargall Y, D'Souza J, Camposilvan I, Hanna WC, Finley CJ. Pneumonectomy: The Burden of Death After Discharge and Predictors of Surgical Mortality. Ann Thorac Surg 2014; 98:1976-81; discussion 1981-2. [DOI: 10.1016/j.athoracsur.2014.06.068] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 06/06/2014] [Accepted: 06/24/2014] [Indexed: 11/26/2022]
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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: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2215-45. [PMID: 25085962 DOI: 10.1161/cir.0000000000000105] [Citation(s) in RCA: 468] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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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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Fixation using alternative implants for the treatment of hip fractures (FAITH): design and rationale for a multi-centre randomized trial comparing sliding hip screws and cancellous screws on revision surgery rates and quality of life in the treatment of femoral neck fractures. BMC Musculoskelet Disord 2014; 15:219. [PMID: 24965132 PMCID: PMC4230242 DOI: 10.1186/1471-2474-15-219] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 06/18/2014] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Hip fractures are a common type of fragility fracture that afflict 293,000 Americans (over 5,000 per week) and 35,000 Canadians (over 670 per week) annually. Despite the large population impact the optimal fixation technique for low energy femoral neck fractures remains controversial. The primary objective of the FAITH study is to assess the impact of cancellous screw fixation versus sliding hip screws on rates of revision surgery at 24 months in individuals with femoral neck fractures. The secondary objective is to determine the impact on health-related quality of life, functional outcomes, health state utilities, fracture healing, mortality and fracture-related adverse events. METHODS/DESIGN FAITH is a multi-centre, multi-national randomized controlled trial utilizing minimization to determine patient allocation. Surgeons in North America, Europe, Australia, and Asia will recruit a total of at least 1,000 patients with low-energy femoral neck fractures. Using central randomization, patients will be allocated to receive surgical treatment with cancellous screws or a sliding hip screw. Patient outcomes will be assessed at one week (baseline), 10 weeks, 6, 12, 18, and 24 months post initial fixation. We will independently adjudicate revision surgery and complications within 24 months of the initial fixation. Outcome analysis will be performed using a Cox proportional hazards model and likelihood ratio test. DISCUSSION This study represents major international efforts to definitively resolve the treatment of low-energy femoral neck fractures. This trial will not only change current Orthopaedic practice, but will also set a benchmark for the conduct of future Orthopaedic trials. TRIAL REGISTRATION The FAITH trial is registered at ClinicalTrials.gov (Identifier NCT00761813).
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Robertson L, Atallah E, Stansby G. Pharmacological treatment of vascular risk factors for reducing mortality and cardiovascular events in patients with abdominal aortic aneurysm. Cochrane Database Syst Rev 2014:CD010447. [PMID: 24449038 DOI: 10.1002/14651858.cd010447.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Pharmacological prophylaxis has been proven to reduce the risk of cardiovascular events in patients with atherosclerotic occlusive arterial disease. However, the role of prophylaxis in patients with abdominal aortic aneurysm (AAA) remains unclear. Several studies have shown that despite successful repair, those with AAA have a poorer rate of survival than healthy controls. People with AAA have an increased prevalence of coronary heart disease and risk of cardiovascular events. Despite this association, little is known about the effectiveness of pharmacological prophylaxis in reducing cardiovascular risk in people with AAA. OBJECTIVES To determine the long-term effectiveness of antiplatelet, antihypertensive or lipid-lowering medication in reducing mortality and cardiovascular events in people with abdominal aortic aneurysm (AAA). SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2013) and CENTRAL (2013, Issue 3). Reference lists of relevant articles were also checked. SELECTION CRITERIA Randomised controlled trials in which people with AAA were randomly allocated to one prophylactic treatment versus another, a different regimen of the same treatment, a placebo, or no treatment were eligible for inclusion in this review. Primary outcomes included all-cause mortality and cardiovascular mortality. DATA COLLECTION AND ANALYSIS Selection of the studies, quality assessment and data extraction were completed independently by two review authors. Any disagreements were resolved by discussion. Only one study was included in the review, therefore meta-analysis could not be performed. MAIN RESULTS One randomised controlled study was included in the review. A subgroup of 227 patients with AAA received either metoprolol (N = 111) or placebo (N = 116). There was no clear evidence that metoprolol reduced all-cause mortality (odds ratio (OR) 0.17, 95% confidence interval (CI) 0.02 to 1.41), cardiovascular death (OR 0.20, 95% CI 0.02 to 1.76), AAA-related death (OR 1.05, 95% CI 0.06 to 16.92) or increased nonfatal cardiovascular events (OR 1.44, 95% CI 0.58 to 3.57) 30 days postoperatively. Furthermore, at six months postoperatively, estimated effects were compatible with benefit and harm for all-cause mortality (OR 0.71, 95% CI 0.26 to 1.95), cardiovascular death (OR 0.73, 95% CI 0.23 to 2.39) and nonfatal cardiovascular events (OR 1.41, 95% CI 0.59 to 3.35). Adverse drug effects were reported for the whole study population and were not available for the subgroup of participants with AAA. The study was deemed to be at a generally low risk of bias. AUTHORS' CONCLUSIONS Due to the limited number of trials, there is insufficient evidence to draw any conclusions about the effectiveness of cardiovascular prophylaxis in reducing mortality and cardiovascular events in people with AAA. Further good-quality randomised controlled trials examining many types of prophylaxis with long-term follow-up are required before firm conclusions can be made.
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Affiliation(s)
- Lindsay Robertson
- Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, High Heaton, Newcastle upon Tyne, UK, NE7 7DN
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Leslie K, Myles P, Devereaux P, Williamson E, Rao-Melancini P, Forbes A, Xu S, Foex P, Pogue J, Arrieta M, Bryson G, Paul J, Paech M, Merchant R, Choi P, Badner N, Peyton P, Sear J, Yang H. Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Br J Anaesth 2013; 111:382-90. [PMID: 23611915 DOI: 10.1093/bja/aet120] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This post hoc analysis aimed to determine whether neuraxial block was associated with a composite of cardiovascular death, non-fatal myocardial infarction (MI) and non-fatal cardiac arrest within 30 days of randomization in POISE trial patients. METHODS A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were randomized to β-blocker or placebo. Neuraxial block was defined as spinal, lumbar or thoracic epidural anaesthesia. Logistic regression, with weighting using estimated propensity scores, was used to determine the association between neuraxial block and primary and secondary outcomes. RESULTS Neuraxial block was associated with an increased risk of the primary outcome [287 (7.3%) vs 229 (5.7%); odds ratio (OR), 1.24; 95% confidence interval (CI), 1.02-1.49; P=0.03] and MI [230 (5.9%) vs 177 (4.4%); OR, 1.32; 95% CI, 1.07-1.64; P=0.009] but not stroke [23 (0.6%) vs 32 (0.8%); OR, 0.76; 95% CI, 0.44-1.33; P=0.34], death [96 (2.5%) vs 111 (2.8%); OR, 0.87; 95% CI, 0.65-1.17; P=0.37] or clinically significant hypotension [522 (13.4%) vs 484 (12.1%); OR, 1.13; 95% CI, 0.99-1.30; P=0.08]. Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [86 (12.1%) vs 119 (5.4%); OR, 2.95; 95% CI, 2.00-4.35; P<0.001]. CONCLUSIONS In patients at high risk of cardiovascular morbidity, neuraxial block was associated with an increased risk of adverse cardiovascular outcomes, which could be causal or because of residual confounding.
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Affiliation(s)
- K Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia.
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Rojas Y, Finnerty CC, Radhakrishnan RS, Herndon DN. Burns: an update on current pharmacotherapy. Expert Opin Pharmacother 2012; 13:2485-94. [PMID: 23121414 DOI: 10.1517/14656566.2012.738195] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The worldwide occurrence of burn injuries remains high despite efforts to reduce injury incidence through public awareness campaigns and improvements in living conditions. In 2004, almost 11 million people experienced burns severe enough to warrant medical treatment. Advances over the past several decades in aggressive resuscitation, nutrition, excision and grafting have reduced morbidity and mortality. Incorporation of pharmacotherapeutics into treatment regimens may further reduce complications of severe burn injuries. AREAS COVERED Severe burn injuries, as well as other forms of stress and trauma, trigger a hypermetabolic response that, if left untreated, impedes recovery. In the past two decades, use of anabolic agents, β-adrenergic receptor antagonists and anti-hyperglycemic agents has successfully counteracted post-burn morbidities including catabolism, the catecholamine-mediated response and insulin resistance. Here, the authors review the most up-to-date information on currently used pharmacotherapies in the treatment of these sequelae of severe burns and the insights that have expanded the understanding of the pathophysiology of severe burns. EXPERT OPINION Existing drugs offer promising advances in the care of burn injuries. Continued gains in the understanding of the molecular mechanisms driving the hypermetabolic response will enable the application of additional existing drugs to be broadened to further attenuate the hypermetabolic response.
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Affiliation(s)
- Yesenia Rojas
- Shriners Hospitals for Children, Galveston, TX 77550, USA
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Chopra V, Eagle KA. Perioperative mischief: the price of academic misconduct. Am J Med 2012; 125:953-5. [PMID: 22884175 DOI: 10.1016/j.amjmed.2012.03.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 10/28/2022]
Abstract
Recent allegations of fraud committed by one of the most prolific researchers in perioperative medicine, Don Poldermans, have left many clinicians in a state of disbelief. With over 500 peer-reviewed publications, Poldermans heavily influenced the clinical practice of perioperative beta-blockers and statins in noncardiac surgery, shaping guidelines and national policies on the use of these treatments. The effects of fraud in perioperative medicine are particularly caustic owing to a profound domino effect. Many investigators devoted their academic careers to following the footsteps of investigators such as Poldermans. Similarly, funding agencies supported this line of enquiry, incurring significant cost and expense. Most importantly, hundreds of patients were exposed to treatments that may have been harmful in an effort to advance this research agenda. How should perioperative clinicians utilize beta blockade now that a considerable portion of the literature is enshrouded in uncertainty? In this brief review, we reiterate and emphasize basic principles about the indications and administration of perioperative beta blockade. Because research misconduct in perioperative medicine can be so damaging, we present strategies to prevent such events in the future. Without such reform, fraud in research may very well continue. The price for such misconduct is simply too great to pay.
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Affiliation(s)
- Vineet Chopra
- Division of General Internal Medicine, University of Michigan Health System, Ann Arbor, MI 48109, USA.
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Leslie K, Myles PS, Halliwell R, Paech MJ, Short TG, Walker S. Beta-Blocker management in High-Risk Patients Presenting for Non-Cardiac Surgery: Before and after the POISE Trial. Anaesth Intensive Care 2012; 40:319-27. [DOI: 10.1177/0310057x1204000216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The POISE Trial was a randomised, placebo-controlled, double-blind study of the effectiveness of perioperative beta-blockade in preventing cardiac events including death in 8351 patients. Our hypothesis was that knowledge of the results of the POISE Trial would either increase or decrease the use of effective perioperative beta-blockade, depending on the result. Patients presenting for non-cardiac surgery and at risk of perioperative cardiac events were recruited in two cohorts before and after the release of the POISE Trial results. Effective perioperative beta-blockade was defined as heart rate <65 beats per minute for at least 80% of the perioperative period in patients prescribed beta-blockers. Effective perioperative beta-blockade was achieved in 22 (11.5%) of 191 patients prescribed perioperative beta-blockade in the first cohort (n=392) and seven (6%) of 118 patients in the second cohort (n=241) (P=0.10). Effective heart rate control was achieved in 29 (9%) patients prescribed perioperative beta-blockers compared with 10 (3%) patients not prescribed perioperative beta-blockers (P=0.001). The rate of implementation of effective beta-blockade was low before POISE and this did not change significantly after publication. Our finding does not provide reliable evidence of a change in practice as a result of the POISE Trial.
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Affiliation(s)
- K. Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Department of Pharmacology, University of Melbourne; Department of Epidemiology and Preventive Medicine, Monash University; Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Academic Board of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria; National Health and Medical Research Council, Canberra, Australian Capital Territory; Department of Anaesthesia, Westmead Hospital, Sydney,
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Honorary Professorial Fellow, Department of Pharmacology, University of Melbourne and Honorary Adjunct Professor, Department of Epidemiology and Preventive Medicine
| | - P. S. Myles
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Department of Pharmacology, University of Melbourne; Department of Epidemiology and Preventive Medicine, Monash University; Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Academic Board of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria; National Health and Medical Research Council, Canberra, Australian Capital Territory; Department of Anaesthesia, Westmead Hospital, Sydney,
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital; Professor, Academic Board of Anaesthesia and Perioperative Medicine, Monash University and Practitioner Fellow, National Health and Medical Research Council, Canberra, Australian Capital Territory
| | - R. Halliwell
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Department of Pharmacology, University of Melbourne; Department of Epidemiology and Preventive Medicine, Monash University; Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Academic Board of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria; National Health and Medical Research Council, Canberra, Australian Capital Territory; Department of Anaesthesia, Westmead Hospital, Sydney,
- Department of Anaesthesia, Westmead Hospital, Sydney, New South Wales
| | - M. J. Paech
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Department of Pharmacology, University of Melbourne; Department of Epidemiology and Preventive Medicine, Monash University; Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Academic Board of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria; National Health and Medical Research Council, Canberra, Australian Capital Territory; Department of Anaesthesia, Westmead Hospital, Sydney,
- School of Medicine and Pharmacology, University of Western Australia and Consultant Anaesthetist, Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia
| | - T. G. Short
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Department of Pharmacology, University of Melbourne; Department of Epidemiology and Preventive Medicine, Monash University; Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Academic Board of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria; National Health and Medical Research Council, Canberra, Australian Capital Territory; Department of Anaesthesia, Westmead Hospital, Sydney,
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - S. Walker
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital; Department of Pharmacology, University of Melbourne; Department of Epidemiology and Preventive Medicine, Monash University; Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Academic Board of Anaesthesia and Perioperative Medicine, Monash University, Melbourne, Victoria; National Health and Medical Research Council, Canberra, Australian Capital Territory; Department of Anaesthesia, Westmead Hospital, Sydney,
- Department of Anaesthesia, Middlemore Hospital, Auckland, New Zealand
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24
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Karthikeyan V, Ananthasubramaniam K. Coronary risk assessment and management options in chronic kidney disease patients prior to kidney transplantation. Curr Cardiol Rev 2011; 5:177-86. [PMID: 20676276 PMCID: PMC2822140 DOI: 10.2174/157340309788970342] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2008] [Revised: 10/15/2008] [Accepted: 10/18/2008] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular disease remains the most important cause of morbidity and mortality among kidney transplant recipients. Nearly half the deaths in transplanted patients are attributed to cardiac causes and almost 5% of these deaths occur within the first year after transplantation. The ideal strategies to screen for coronary artery disease (CAD) in chronic kidney disease patients who are evaluated for kidney transplantation (KT) remain controversial. The American Society of Transplantation recommends that patients with diabetes, prior history of ischemic heart disease or an abnormal ECG, or age ≥50 years should be considered as high-risk for CAD and referred for a cardiac stress test and only those with a positive stress test, for coronary angiography. Despite these recommendations, vast variations exist in the way these patients are screened for CAD at different transplant centers. The sensitivity and specificity of noninvasive cardiac tests in CKD patients is much lower than that in the general population. This has prompted the use of direct diagnostic cardiac catheterization in high-risk patients in several transplant centers despite the risks associated with this invasive procedure. No large randomized controlled trials exist to date that address these issues. In this article, we review the existing literature with regards to the available data on cardiovascular risk screening and management options in CKD patients presenting for kidney transplantation and outline a strategy for approach to these patients.
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Affiliation(s)
- Vanji Karthikeyan
- Division of Nephrology and Transplantation and the Heart and Vascular Institute, Henry Ford Hospital Detroit MI, USA
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25
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Devereaux PJ, Guyatt G, Yang H, Yusuf S. Essay for the CIHR/CMAJ award: impact of the Perioperative Ischemic Evaluation (POISE) trial. CMAJ 2011; 183:E351-3. [PMID: 21422131 DOI: 10.1503/cmaj.110292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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26
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Preckel B, Poels M, Wappler F, Schlack W, Buhre W. [Perioperative beta-receptor blockade. For and against]. Anaesthesist 2010; 59:643-51. [PMID: 20383478 DOI: 10.1007/s00101-010-1703-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Results from recent studies have questioned the application of beta-receptor blockers for reduction of morbidity and mortality during the perioperative period. This holds true especially for patients with no or only low cardiac risk. Although beta-receptor blockade was a form of standard therapy at the end of the 1990s, data today show no clear evidence for such a therapy not even in patients at risk for cardiac events. At least in patients with low risk the initiation of beta-receptor blockade during the perioperative period might lead to side-effects, thereby increasing morbidity and mortality.
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Affiliation(s)
- B Preckel
- Department of Anesthesiology, Academic Medical Centre AMC, University of Amsterdam, Meibergdreef 9, 1100 Amsterdam, The Netherlands.
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Abstract
Hip fractures are a significant cause of morbidity and mortality worldwide and the burden of disability associated with hip fractures globally vindicate the need for high-quality research to advance the care of patients with hip fractures. Historically, large, multi-centre randomized controlled trials have been rare in the orthopaedic trauma literature. Similar to other medical specialties, orthopaedic research is currently undergoing a paradigm shift from single centre initiatives to larger collaborative groups. This is evident with the establishment of several collaborative groups in Canada, in the United States, and in Europe, which has proven that multi-centre trials can be extremely successful in orthopaedic trauma research.Despite ever increasing literature on the topic of his fractures, the optimal treatment of hip fractures remains unknown and controversial. To resolve this controversy large multi-national collaborative randomized controlled trials are required. In 2005, the International Hip Fracture Research Collaborative was officially established following funding from the Canadian Institute of Health Research International Opportunity Program with the mandate of resolving controversies in hip fracture management. This manuscript will describe the need, the information, the organization, and the accomplishments to date of the International Hip Fracture Research Collaborative.
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Alonso-Coello P, Alvarez C, Cruz P, Torán L, De Nadal M, Martínez M, Paniagua P, Mases A, Urrutia G. [Beta-blockers in patients undergoing noncardiac surgery: implications of the POISE study]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:232-238. [PMID: 19537263 DOI: 10.1016/s0034-9356(09)70377-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- P Alonso-Coello
- Centro Cochrane Iberoamericano, Servicio de Epidemiología Clínica y Salud Pública, Hospital de la Santa Creu i Sant Pau, Barcelona
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Mauck KF, Manjarrez EC, Cohn SL. Perioperative cardiac evaluation: assessment, risk reduction, and complication management. Clin Geriatr Med 2009; 24:585-605, vii. [PMID: 18984375 DOI: 10.1016/j.cger.2008.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Perioperative cardiac complications are among the most feared outcomes after surgery. Using evidence-based guidelines and expert opinion, physicians can perform a risk assessment and decide whether further cardiac testing, medical therapy, or coronary intervention is necessary to optimize the patient's medical condition prior to surgery. This article reviews the major concepts and recommendations from the ACC guidelines for preoperative cardiac evaluation and perioperative management to reduce risk. Medical management of the major postoperative cardiac complications is also discussed.
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Affiliation(s)
- Karen F Mauck
- Division of General Internal Medicine, Mayo Clinic and Mayo College of Medicine, 200 1st Street SW, Rochester, MN 55905, USA
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Choi PT, Beattie WS, Bryson GL, Paul JE, Yang H. Effects of neuraxial blockade may be difficult to study using large randomized controlled trials: the PeriOperative Epidural Trial (POET) Pilot Study. PLoS One 2009; 4:e4644. [PMID: 19247497 PMCID: PMC2645707 DOI: 10.1371/journal.pone.0004644] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 01/16/2009] [Indexed: 11/18/2022] Open
Abstract
Background Early randomized controlled trials have suggested that neuraxial blockade may reduce cardiorespiratory complications after non-cardiothoracic surgery, but recent larger trials have been inconclusive. We conducted a pilot study to assess the feasibility of conducting a large multicentre randomized controlled trial in Canada. Methodology/Principal Findings After Research Ethics Board approvals from the participating institutions, subjects were recruited if they were ≥45 years old, had an expected hospital stay ≥48 hours, were undergoing a noncardiothoracic procedure amenable to epidural analgesia, met one of six risk criteria, and did not have contraindications to neuraxial blockade. After informed consent, subjects were randomly allocated to combined epidural analgesia (epidural group) and neuraxial anesthesia, with or without general anesthesia, or intravenous opioid analgesia (IV group) and general anesthesia. The primary outcomes were the rate of recruitment and the percents of eligible patients recruited, crossed over, and followed completely. Feasibility targets were defined a priori. A blinded, independent committee adjudicated the secondary clinical outcomes. Subjects were followed daily while in hospital and then at 30 days after surgery. Analysis was intention-to-treat. Over a 15-month period, the recruitment rate was 0.5±0.3 (mean±SEM) subjects per week per centre; 112/494 (22.7%) eligible subjects were recruited at four tertiary-care teaching hospitals in Canada. Thirteen (26.5%) of 49 subjects in the epidural group crossed over to the IV group; seven (14.3%) were due to failed or inadequate analgesia or complications from epidural analgesia. Five (9.8%) of 51 subjects in the IV group crossed over to the epidural group but none were due to inadequate analgesia or complications. Ninety-eight (97.0%) of 101 subjects were successfully followed up until 30 days after their surgery. Conclusion/Significance Of the criteria we defined for the feasibility of a full-scale trial, only the follow-up target was met. The other feasibility outcomes did not meet our preset criteria for success. The results suggest that a large multicentre trial may not be a feasible design to study the perioperative effects of neuraxial blockade. Trial Registration ClinicalTrials.gov NCT 0221260 Controlled-Trials.com ISRCTN 35629817
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Affiliation(s)
- Peter T Choi
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
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31
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Priebe HJ. Perioperative Cardioprotection. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-77383-4_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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32
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Hepner DL, Correll DJ, Beckman JA, Klickovich RJ, Park KH, Govindarajulu U, Bader AM. Needs analysis for the development of a preoperative clinic protocol for perioperative beta-blocker therapy. J Clin Anesth 2008; 20:580-8. [DOI: 10.1016/j.jclinane.2008.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 06/02/2008] [Accepted: 06/03/2008] [Indexed: 10/21/2022]
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[Perioperative pharmacological myocardial protection. Systematic literature-based process optimization]. Anaesthesist 2008; 57:655-69. [PMID: 18597062 DOI: 10.1007/s00101-008-1396-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Patients with major cardiac risk factors have been suggested to benefit from perioperative beta-blockade. However, the scientific literature on perioperative beta-blockade needs to be interpreted carefully. So far treatment recommendations for millions of patients are based on heterogeneous data from randomized trials with divergent study results. The evidence for a beneficial effect of perioperative beta-blockers is sufficient only for a limited subpopulation of high cardiac risk patients undergoing vascular surgery. Perioperative beta-blocker treatment is not useful in patients with intermediate risk and may even be harmful in patients with low cardiac risk. Therefore, an individualized risk-benefit analysis is an important prerequisite for a rational therapy that may be based on a standardized protocol including the Revised Cardiac Risk Index. Such a protocol is presented in this article. A recently reported trial (POISE) demonstrated that perioperative treatment with high doses of oral metoprolol efficiently reduces the incidence of cardiovascular events. However, due to severe adverse effects (hypotension, bradycardia, stroke) the total mortality was increased. Thus, dose adjustments, safety aspects, and monitoring of beta-blocker therapy seem to be mandatory. So far evidence from relevant trials about how to best implement perioperative beta-blockade is lacking. This article offers a simple clinical concept for this purpose.
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35
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Affiliation(s)
- Andrew D. Auerbach
- From the Division of Hospital Medicine, University of California San Francisco
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36
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Sear JW, Giles JW, Howard-Alpe G, Foëx P. Perioperative beta-blockade, 2008: what does POISE tell us, and was our earlier caution justified? Br J Anaesth 2008; 101:135-8. [PMID: 18614596 DOI: 10.1093/bja/aen194] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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37
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The effect of metoprolol on perioperative outcome in coronary patients undergoing nonvascular abdominal surgery. J Clin Anesth 2008; 20:284-9. [DOI: 10.1016/j.jclinane.2007.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 11/30/2007] [Accepted: 12/22/2007] [Indexed: 11/18/2022]
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Abstract
Esophageal resection is a formidable operation associated with high morbidity and mortality. Anesthetic management may contribute to the containment of respiratory failure and anastomotic leakage by the use of thoracic epidural analgesia, protective ventilation strategies, prevention of tracheal aspiration, and judicious fluid management.
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Affiliation(s)
- Ju-Mei Ng
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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39
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Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Málaga G, Avezum A, Chan M, Montori VM, Jacka M, Choi P. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371:1839-47. [PMID: 18479744 DOI: 10.1016/s0140-6736(08)60601-7] [Citation(s) in RCA: 1260] [Impact Index Per Article: 78.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Trials of beta blockers in patients undergoing non-cardiac surgery have reported conflicting results. This randomised controlled trial, done in 190 hospitals in 23 countries, was designed to investigate the effects of perioperative beta blockers. METHODS We randomly assigned 8351 patients with, or at risk of, atherosclerotic disease who were undergoing non-cardiac surgery to receive extended-release metoprolol succinate (n=4174) or placebo (n=4177), by a computerised randomisation phone service. Study treatment was started 2-4 h before surgery and continued for 30 days. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal cardiac arrest. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00182039. FINDINGS All 8351 patients were included in analyses; 8331 (99.8%) patients completed the 30-day follow-up. Fewer patients in the metoprolol group than in the placebo group reached the primary endpoint (244 [5.8%] patients in the metoprolol group vs 290 [6.9%] in the placebo group; hazard ratio 0.84, 95% CI 0.70-0.99; p=0.0399). Fewer patients in the metoprolol group than in the placebo group had a myocardial infarction (176 [4.2%] vs 239 [5.7%] patients; 0.73, 0.60-0.89; p=0.0017). However, there were more deaths in the metoprolol group than in the placebo group (129 [3.1%] vs 97 [2.3%] patients; 1.33, 1.03-1.74; p=0.0317). More patients in the metoprolol group than in the placebo group had a stroke (41 [1.0%] vs 19 [0.5%] patients; 2.17, 1.26-3.74; p=0.0053). INTERPRETATION Our results highlight the risk in assuming a perioperative beta-blocker regimen has benefit without substantial harm, and the importance and need for large randomised trials in the perioperative setting. Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol.
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40
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Chronic kidney disease and postoperative mortality: A systematic review and meta-analysis. Kidney Int 2008; 73:1069-81. [DOI: 10.1038/ki.2008.29] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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41
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Poldermans D, Hoeks SE, Feringa HH. Pre-Operative Risk Assessment and Risk Reduction Before Surgery. J Am Coll Cardiol 2008; 51:1913-24. [DOI: 10.1016/j.jacc.2008.03.005] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2007] [Revised: 03/03/2008] [Accepted: 03/04/2008] [Indexed: 10/22/2022]
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Beattie WS, Wijeysundera DN, Karkouti K, McCluskey S, Tait G. Does Tight Heart Rate Control Improve Beta-Blocker Efficacy? An Updated Analysis of the Noncardiac Surgical Randomized Trials. Anesth Analg 2008; 106:1039-48, table of contents. [DOI: 10.1213/ane.0b013e318163f6a9] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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44
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The Nurse Practitioner Role in Evidence-Based Medication Strategies. J Perianesth Nurs 2008; 23:87-93. [DOI: 10.1016/j.jopan.2007.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Accepted: 09/19/2007] [Indexed: 11/22/2022]
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Golembiewski J. Beta-blockers in the perioperative setting. J Perianesth Nurs 2008; 23:133-6. [PMID: 18362010 DOI: 10.1016/j.jopan.2008.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2008] [Accepted: 01/07/2008] [Indexed: 11/16/2022]
Affiliation(s)
- Julie Golembiewski
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA.
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Abstract
PURPOSE OF REVIEW Perioperative beta-blockade and statin therapy have been advocated to reduce cardiac risk of noncardiac surgery. This review evaluates recent articles published on the cardioprotective effects of perioperative therapy with these medications. RECENT FINDINGS Initial studies evaluating beta-blocker therapy during the perioperative period suggested that beta-blockers may be beneficial in reducing cardiac deaths and myocardial infarctions. Later studies and recent meta-analyses, however, are less favorable and suggest that beta-blockers may be associated with increased incidence of bradycardia and hypotension. One randomized trial and several cohort studies have found a significant reduction in cardiovascular complications with perioperative statin therapy. Additionally, statin withdrawal is associated with increased postoperative cardiac risk. SUMMARY Based upon the available evidence and guidelines, patients currently taking beta-blockers should continue these agents. Patients undergoing vascular surgery who are at high cardiac risk should also take beta-blockers. The question remains regarding the best protocol to initiate perioperative beta-blockade. Statins should be continued in patients already taking these agents prior to surgery. The optimal duration and time of initiation of statin therapy remains unclear.
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47
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London MJ. Beta blockers and alpha2 agonists for cardioprotection. Best Pract Res Clin Anaesthesiol 2008; 22:95-110. [DOI: 10.1016/j.bpa.2007.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Given the increasing complexity of hospitalized patients and the increasing specialization among surgeons, there is greater reliance on hospitalists for preoperative assessment. Several institutions have developed surgery/medicine comanagement teams that jointly care for patients in the perioperative setting. Despite a growing body of evidence, it is important to recognize there are many gaps in the perioperative literature. This has led to considerable dependence on consensus statements and expert opinion when evaluating patients perioperatively. This review focuses on the preoperative cardiovascular and pulmonary evaluation of the hospitalized patient: the two systems responsible for the greatest morbidity and mortality. Prevention of postoperative venous thromboembolism and management of perioperative hyperglycemia are also discussed.
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Affiliation(s)
- Paul J Grant
- University of Michigan Medical School, Division of General Medicine, Department of Internal Medicine, Ann Arbor, MI 48109-5376, USA.
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49
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Current World Literature. Curr Opin Anaesthesiol 2008; 21:85-8. [DOI: 10.1097/aco.0b013e3282f5415f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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50
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