Statin in Combination With β-Blocker Therapy Reduces Postoperative Stroke After Coronary Artery Bypass Graft Surgery

Coronary heart disease increases the risk of perioperative ischemic stroke after noncardiac surgery: A retrospective cohort study

OBJECTIVE

To investigate the association between coronary heart disease (CHD) and the risk of perioperative ischemic stroke in patients undergoing noncardiac surgery.

METHODS

This retrospective study evaluated the incidence of ischemic stroke within 30 days after a noncardiac surgery. A cohort of 221,541 patients who underwent noncardiac surgery between January 2008 and August 2019 was segregated according to whether they were diagnosed with CHD. Primary, sensitivity, and subgroup logistic regression analyses were conducted to confirm that CHD is an independent risk factor for perioperative ischemic stroke. Propensity score matching analysis was used to account for the potential residual confounding effect of covariates.

RESULTS

Among the 221,541 included patients undergoing noncardiac surgery, 484 patients (0.22%) experienced perioperative ischemic stroke. The risk of perioperative ischemic stroke was higher in patients with CHD (0.7%) compared to patients without CHD (0.2%), and multivariate logistic regression analysis showed that CHD was associated with a significantly increased risk of perioperative ischemic stroke (odds ratio (OR), 3.7943; 95% confidence interval (CI) 2.865-4.934; p < 0.001). In a subset of patients selected by propensity score matching (PSM) in which all covariates between the two groups were well balanced, the association between CHD and increased risk of perioperative ischemic stroke remained significantly significant (OR 1.8150; 95% CI, 1.254-2.619; p = 0.001). In the subgroup analysis stratified by age, preoperative β-blockers, and fibrinogen-to-albumin ratio (FAR), the association between CHD and perioperative ischemic stroke was stable (p for interaction >0.05). Subgroup analyses also showed that CHD was significantly increased the risk of perioperative ischemic stroke in the preoperative mean arterial pressure (MAP) ≥94.2 mmHg subgroups (p for interaction <0.001).

CONCLUSION

CHD is significantly associated with an increased risk of perioperative ischemic stroke and is an independent risk factor for perioperative ischemic stroke after noncardiac surgery. Strict control of preoperative blood pressure may reduce the risk of perioperative ischemic stroke for patients with CHD undergoing noncardiac surgery.

Effects of a Secondary Prevention Combination Therapy with beta-Blocker and Statin on Major Adverse Cardiovascular Events in Acute Coronary Syndrome Patients

BACKGROUND The efficacy of a beta-blocker or statin alone versus combination therapy is uncertain. We compared the effects of a combination of beta-blocker and statin with those of one-drug therapies with regard to the occurrence of a major adverse cardiovascular event (MACE) in patients with acute coronary syndrome (ACS). MATERIAL AND METHODS From 2011 to 2013, 636 ACS patients were included. Based on their risk category, enrolled subjects were assigned into 4 groups receiving consistent beta-blocker and/or statin treatment: no therapy group (n=139), with never use or inconsistent use beta-blocker and statin; beta-blocker monotherapy group (n=71); statin monotherapy group (n=149); and cotherapy group (n=277). RESULTS Men composed 66.8% of the cohort, which had a mean age of 60.42±9.83 years. Compared with the no therapy group, the statin monotherapy group and cotherapy group had a lower risk of MACE (statin monotherapy group: adjusted hazard ratio [HR] 0.35, 95% confidence interval [CI] 0.20-0.60, P<.001; cotherapy group: adjusted HR 0.16, 95% CI 0.09-0.28, P<.001). Subgroup analysis indicated that, compared with beta-blocker monotherapy and statin monotherapy, cotherapy significantly reduced the risks of MACE occurrences in ACS patients (beta-blocker monotherapy group: adjusted HR 0.28, 95% CI 0.13-0.59, P=.001; statin monotherapy group: adjusted HR 0.54, 95% CI 0.29-0.98, P=.044). CONCLUSIONS Beta-blocker and statin combination therapy lowered the risk of developing MACE in ACS patients.

The Role of Statins in the Management of Patients Undergoing Coronary Artery Bypass Grafting

Each year, a large number of patients undergo coronary artery bypass grafting surgery (CABG) worldwide. Accumulating evidence suggests that the preoperative administration of statins might be useful in preventing adverse events after CABG. In the present review, we discuss the role of statins in the perioperative management of patients undergoing CABG. Preoperative administration of statins in these patients substantially reduces the risk of postoperative atrial fibrillation and shortens hospital and intensive care unit (ICU) stay. Atorvastatin appears to be more effective, particularly when administered at high doses. Given these benefits and the safety of statins, their administration should be considered in patients undergoing CABG, even though the statins do not appear to affect the incidence of cardiovascular events and overall mortality perioperatively.

Lack of Association between Preoperative Statin Use and Respiratory and Neurologic Complications after Cardiac Surgery

Background

Statins may reduce the risk of pulmonary and neurologic complications after cardiac surgery.

Methods

The authors acquired data for adults who had coronary artery bypass graft, valve surgery, or combined procedures. The authors matched patients who took statins preoperatively to patients who did not. First, the authors assessed the association between preoperative statin use and the primary outcomes of prolonged ventilation (more than 24 h), pneumonia (positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia), and in-hospital all-cause mortality, using logistic regressions. Second, the authors analyzed the collapsed composite of neurologic complications using logistic regression. Intensive care unit and hospital length of stay were evaluated with Cox proportional hazard models.

Results

Among 14,129 eligible patients, 6,642 patients were successfully matched. There was no significant association between preoperative statin use and prolonged ventilation (statin: 408/3,321 [12.3%] vs. nonstatin: 389/3,321 [11.7%]), pneumonia (44/3,321 [1.3%] vs. 54/3,321 [1.6%]), and in-hospital mortality (52/3,321 [1.6%] vs. 43/3,321 [1.3%]). The estimated odds ratio was 1.06 (98.3% CI, 0.88 to 1.27) for prolonged ventilation, 0.81 (0.50 to 1.32) for pneumonia, and 1.21 (0.74 to 1.99) for in-hospital mortality. Neurologic outcomes were not associated with preoperative statin use (53/3,321 [1.6%] vs. 56/3,321 [1.7%]), with an odds ratio of 0.95 (0.60 to 1.50). The length of intensive care unit and hospital stay was also not associated with preoperative statin use, with a hazard ratio of 1.04 (0.98 to 1.10) for length of hospital stay and 1.00 (0.94 to 1.06) for length of intensive care unit stay.

Conclusions

Preoperative statin use did not reduce pulmonary or neurologic complications after cardiac surgery.

Coronary artery bypass grafting for left main disease and the risk of stroke: Incidence, aetiology and prevention

This review explores the association between left main disease and the increased risk of perioperative stroke following coronary artery bypass grafting, specifically addressing the potential underlying mechanisms and its potential prevention. In particular, this correlation appears stronger for patients with left main disease when compared to patients with isolated triple vessel disease. Even though evidence on this topic is limited and of modest quality, there appears to be a significant association between ascending aorta atherosclerosis and coronary artery disease. Furthermore, there seems to be a relationship between the severity and extent of carotid artery stenosis and coronary artery disease. Carotid artery disease is itself associated with atherosclerosis of the ascending aorta, a well-recognised risk factor for postoperative atheroembolic stroke. The association between left main disease, ascending aorta atherosclerosis and carotid artery stenosis may reflect an increased systemic atherosclerotic burden and hence explain, at least partially, the higher risk of perioperative cerebrovascular events. Potential pre-, intra- and post-operative strategies for stroke prevention are discussed.

Effects of five preoperative cardiovascular drugs on mortality after coronary artery bypass surgery: A retrospective analysis of an observational study of 16, 192 patients

BACKGROUND

Statins reduce risk from coronary artery bypass graft (CABG) surgery, but the influence of angiotensin-converting enzyme inhibitors, alpha-2 adrenergic agonists, calcium channel blockers and beta-blockers is less clear.

OBJECTIVES

We investigated the association of each of these drugs with perioperative risk, accounting for different confounders, and evaluated the class, dose-response and long-term protective effect of statins.

DESIGN

A retrospective analysis of observational data.

SETTING

United Kingdom.

PATIENTS

Sixteen thousand one hundred and ninety-two patients who underwent CABG surgery during the period 01 January 2004 to 31 December 2013 and contributed data to Primary Care Clinical Practice Research Datalink.

EXPOSURE VARIABLES

Cardiovascular drugs.

OUTCOME MEASURE

Perioperative mortality within 30 days of surgery.

STATISTICAL ANALYSIS

Five multivariable logistic regression models and a further Cox regression model were used to account for preexisting cardiovascular and other comorbidities along with lifestyle factors such as BMI, smoking and alcohol use.

RESULTS

Exposure to statins was most prevalent (85.1% of patients), followed by beta-blockers (72.8%), angiotensin-converting enzyme inhibitors (60.5%), calcium channel blockers (42.8%) and alpha-2 adrenergic agonists (1.2%). The mortality rate was 0.8% in patients not prescribed statins and 0.4% in those on statins. Statins were associated with a statistically significant reduced perioperative mortality in all five logistic regression models with adjusted odds ratios (OR) (95% confidence interval, 95% CI) ranging from 0.26 (0.13 to 0.54) to 0.35 (0.18 to 0.67). Cox regression for perioperative mortality [adjusted hazard ratio (95% CI) 0.40 (0.20 to 0.80)] and 6-month mortality [adjusted hazard ratio (95% CI) 0.63 (0.42 to 0.92)] produced similar results. Of the statin doses tested, only simvastatin 40 mg exerted protective effects. The other cardiovascular drugs lacked consistent effects across models.

CONCLUSION

Statins appear consistently protective against perioperative mortality from CABG surgery in multiple models, an effect not shared by the other cardiovascular drugs. Further data are needed on whether statins exert class and dose-response effects.

Perioperative Statin Therapy for Patients Undergoing Coronary Artery Bypass Grafting

Coronary artery bypass grafting is associated with an intense systemic inflammatory response, which is linked to postoperative complications. Beyond lipid lowering, statins exert a constellation of beneficial actions, including an antiinflammatory role, known as pleiotropic effects. There is increasing evidence that perioperative statin therapy improves outcomes in patients undergoing coronary artery bypass grafting. Statins are underused in the coronary artery bypass grafting population, because perioperative discontinuation remains a common practice. This article provides an extensive review of the available literature on the effect of perioperative statin therapy on post–coronary artery bypass grafting outcomes and weighs the evidence for the concerns about increased incidence of statin-related adverse effects in this setting.

Potassium induced contraction of the internal thoracic artery in vitro is time related: the potential consequences in the analysis of the mechanism of the spasm after coronary artery bypass grafting and in the analysis of the results of in vitro studies

The aim of the present study was to examine how, under in vitro conditions, the human left internal thoracic artery (LITA) reacts to contractile agonist:potassium chloride (KCL) as a function of time, as well as to examine whether a change in the LITA reactivity can correlate with the occurrence of the refractory vascular spasm (RVS). Distal segments of LITA obtained from 33 patients aged 38–73, at the time of routine coronary artery surgical revascularization (CABG). Contractile response to 80 mmol K⁺ was recorded under isometric conditions. In 16 (48,5 %) LITA segments, contractile reaction to K⁺ after experiments ranging 1–10 h were registered. No contractile response even after 10 h of incubation was observed in 17 (51.5 %) LITA segments. Between 120 and 300 min after the beginning of the experiment, the reaction was maximum and amounted up to 300 % control reaction, then decreased. First, with respect to in vitro research isolated by LITA rings, while analyzing the results of the research, one should take into consideration the possibility that during the research, the functional state of the tissues changes and in particular its sensitivity to depolarization of the cell membrane. Second, the change in the sensitivity to depolarization of the cell membrane of the smooth muscles’ LITA might be the potential mechanism causing the occurrence of the postoperative spasm after the CABG treatment.

Perioperative stroke: risk assessment, prevention and treatment

OPINION STATEMENT

Numerous risk factors for perioperative stroke have been identified and many are modifiable. Surgical patients with a history of cerebrovascular disease should be evaluated by a neurologist. Cardiac and cerebrovascular testing is critical in identifying patients at high risk for perioperative stroke. The identification and treatment of carotid disease in the context of upcoming surgery has been a source of controversy. Routine carotid revascularization performed with coronary artery bypass graft (CABG) surgery for incidentally discovered carotid stenosis is not recommended. Prior to aortic manipulation during CABG, epiaortic ultrasound should be performed to identify aortic atheromatous plaques. If possible, preoperative aspirin, beta blocker, statin, and angiotensin converting-enzyme (ACE) inhibitor therapy should be continued in the perioperative period. Patients who are prescribed anticoagulation at high risk of thromboembolism should receive bridging anticoagulation during the perioperative period. The identification and prevention of postoperative atrial fibrillation (AF) is central to stroke prevention. CABG patients should be initiated on beta blockade +/- amiodarone to prevent postoperative AF. Many practitioners have been traditionally nihilistic towards acute perioperative stroke treatment. Given the narrow therapeutic window of treatment options, candidacy is dependent on timely recognition. Intravenous and endovascular thrombolysis/therapies are viable options in selected patients under the guidance and expertise of a neurologist. This article will present the epidemiology of perioperative stroke, the pathophysiology, risk assessment and stratification for common surgeries. The article will additionally focus on treatment options including modifiable risk factor reduction and the perioperative management of medications.

Late stroke: comparison of percutaneous coronary intervention versus coronary artery bypass grafting in patients with multivessel disease and unprotected left main disease: a meta-analysis and review of literature

BACKGROUND AND PURPOSE

Studies have suggested that the early excess risk of stroke in coronary artery bypass grafting (CABG) may be compensated for by a slow but progressive catch-up phenomenon in patients undergoing percutaneous coronary intervention (PCI). We therefore undertook this analysis to compare the temporal stroke risk between PCI and CABG in patients with unprotected left main stenosis and multivessel coronary artery disease.

METHODS

Studies of PCI versus CABG for unprotected left main stenosis and multivessel disease published between January 1994 (stent era) and July 2013 were identified using an electronic search and reviewed using meta-analytic techniques.

RESULTS

We selected 57 reports for the meta-analysis by applying the inclusion and exclusion criteria. The analysis was performed on 80,314 patient records. There was a significantly lower risk of cumulative stroke in patients undergoing PCI with stenting at 1 year (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.42-0.71), 2 years (OR, 0.78; 95% CI, 0.66-0.92), 3 years (OR, 0.79; 95% CI, 0.67-0.92), 4 years (OR, 0.74; 95% CI, 0.56-0.97), and 5 years (OR, 0.79; 95% CI, 0.69-0.91). There was no significant difference in the incidence of stroke because of the small sample size (OR, 0.71; 95% CI, 0.46-1.08) at >5 years between PCI and CABG. Similar results were observed on subgroup analysis (multi-vessel coronary artery disease, unprotected left main, diabetics, and randomized trials) and for stroke within 30 days. Late stroke (stroke>30 days) was similar between the 2 groups.

CONCLUSIONS

There is a significantly lower risk of stroke within 30 days and cumulative stroke with PCI as compared with CABG up to year 5. There is no late catch up of stroke in the PCI arm. The risk of stroke should be weighed in deciding between revascularization strategies.

Neurocognitive outcomes after cardiac surgery

PURPOSE OF REVIEW

To summarize recent studies of neurocognitive dysfunction after cardiac surgery, as well as to outline efforts and approaches toward advancing the field.

RECENT FINDINGS

Observational studies have improved our understanding of the incidence and the trajectory of cognitive decline after cardiac surgery; however, the magnitude of this neurocognitive change remains controversial because of the inconsistent definitions and the lack of a gold-standard diagnostic modality. Nonetheless, physicians commonly see patients with functional and cognitive impairments after cardiac surgery, which utilize healthcare resources and impact quality of life. Novel approaches have utilized advanced neuroimaging techniques as well as innovative monitoring modalities to improve the efficiency of neuroprotective strategies during cardiac surgery.

SUMMARY

Adverse cognitive and neurologic outcomes following cardiac surgery range from discrete neurocognitive deficits to severe neurologic injury such as stroke and even death. The elderly are at higher risk of suffering these outcomes and the public health dimension of this problem is expected to accelerate. Future studies should combine advanced neuroimaging with genomic, transcriptional, proteomic, and metabolomic profiling to improve our understanding of the pathophysiologic mechanisms and optimize the diagnosis, prevention, and treatment of neurocognitive injury.

Preoperative prediction of mortality within 1 year after elective thoracic endovascular aortic aneurysm repair

OBJECTIVE

Thoracic endovascular aortic repair (TEVAR) is known to have a survival benefit over open repair in patients with descending thoracic aneurysms and has become a mainstay of therapy. Because death before 1 year after TEVAR likely indicates an ineffective therapy, we have created a predictive model for death within 1 year using factors available in the preoperative setting.

METHODS

A registry of 526 TEVARs performed at the University of Florida between September 2000 and November 2010 was queried for patients with degenerative descending thoracic aneurysm as their primary pathology. Procedures with emergent or urgent indications were excluded. Preoperatively available variables, such as baseline comorbidities, anatomic-, and procedure-specific planning details, were recorded. Univariate predictors of death were analyzed with multivariable Cox proportional hazards to identify independent predictors of 30-day (death within 30 days) and 1-year mortality (death within 1 year) after TEVAR.

RESULTS

A total of 224 patients were identified and evaluated. The 30-day mortality rate was 3% (n = 7) and the 1-year mortality rate was 15% (n = 33). Multivariable predictors of 1-year mortality (hazard ratios [95% confidence interval]) included: age >70 years (5.8 [2.1-16.0]; P = .001), adjunctive intraoperative procedures (eg, brachiocephalic or visceral stents, or both, concomitant arch debranching procedures; 4.5 [1.9-10.8]; P = .001), peripheral arterial disease (3.0 [1.4-6.7]; P = .006), coronary artery disease (2.4 [1.1-4.9]; P = .02), and chronic obstructive pulmonary disease (1.9 [1.0-3.9]; P = .06). A diagnosis of hyperlipidemia was protective (0.4 [0.2-0.7]; P = .006). When patients were grouped into those with one, two, three, or four or more of these risk factors, the predicted 1-year mortality was 1%, 3%, 10%, 27%, and 54%, respectively.

CONCLUSIONS

Factors are available in the preoperative setting that are predictive of death within 1 year after TEVAR and can guide clinical decision making regarding the timing of repair. Patients with multiple risk factors, such as age ≥ 70 years, coronary artery disease, chronic obstructive pulmonary disease, and a need for an extensive procedure involving adjunctive therapies, have a high predicted mortality within 1 year and may be best served by waiting for a larger aneurysm size to justify the risk of intervention.

Brain damage in cardiac surgery patients

Neuropsychological disorders and brain injury are still a serious problem in cardiac surgery patients. Owing to multifactorial mechanism of brain injury during extracorporeal circulation, the effective and safe protection is extremely difficult. Despite several studies, the ideal neuroprotective treatment has not been found. Based on literature we analysed the main mechanisms of brain injury and new methods of brain protection.

Lipid-lowering therapy and coronary artery bypass graft surgery: what are the benefits?

PURPOSE OF REVIEW

Despite their apparent benefits, statins remain underutilized after coronary artery bypass graft (CABG) surgery. To summarize the literature regarding statin therapy and CABG, we performed a systematic review of the Medline database from 1987-2011 to assess the benefits of statins in CABG patients, including the role of high-dose therapy, and highlight areas for future study.

RECENT FINDINGS

When administered prior to CABG, statins reduce the risk of perioperative mortality, stroke, and atrial fibrillation. After CABG, statins limit the progression of atherosclerosis in native coronary arteries, inhibit the process of saphenous vein graft disease, and improve vein graft patency. Furthermore, postoperative statins reduce the recurrence of cardiovascular events and improve all-cause mortality. High-intensity statin therapy early after surgery may benefit CABG patients, but this is yet to be evaluated prospectively.

SUMMARY

Statins clearly improve the outcomes of CABG patients. In the absence of contraindications, all patients undergoing CABG are candidates for life-long statin therapy, with initiation recommended as soon as coronary disease is documented. Statins should be restarted early after surgery. However, the optimal postoperative lipid-lowering regimen remains unknown and should be the subject of upcoming trials. Strategies directed toward improving statin prescription rates and patient adherence should also be priorities for future research.

Integrating outcome benefit into anesthetic design: the promise of steroids and statins

Steroids and statins may facilitate the integration of anesthetic design with clinical outcome. Although steroids clearly benefit adult cardiac surgical patents, the evidence is weaker in pediatric cardiac surgery. Current large randomized trials of steroids likely will determine the future role of steroids in adult cardiac surgery. In the intensive care unit, steroid therapy is indicated in septic shock that is refractory to fluid and pressor therapy. Recent data, however, indicate that liberal steroid therapy for sepsis may have adverse outcome consequences. A 2nd concern in the intensive care unit is acute adrenal suppression secondary to bolus etomidate therapy because it may be deleterious in patients with septic shock. Possible clinical solutions include alternative induction agents, concomitant steroid therapy, and recent etomidate derivatives. Statins also reduce mortality and atrial fibrillation after cardiac surgery. Furthermore, they slow the progression of rheumatic valvular stenosis, an important consideration in the developing world. Statins also may reduce delirium, stroke, and acute renal injury after cardiac surgery, but further randomized trials are required before definitive recommendations can be formulated. Statins are essential in vascular surgery because they reduce mortality, myocardial ischemia, and acute renal injury. As a result, they have been recommended highly for outcome enhancement in recent perioperative guidelines. Although they may improve survival in sepsis, further investigation is indicated to define their therapeutic role.