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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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Hiraoka E, Tanabe K, Izuta S, Kubota T, Kohsaka S, Kozuki A, Satomi K, Shiomi H, Shinke T, Nagai T, Manabe S, Mochizuki Y, Inohara T, Ota M, Kawaji T, Kondo Y, Shimada Y, Sotomi Y, Takaya T, Tada A, Taniguchi T, Nagao K, Nakazono K, Nakano Y, Nakayama K, Matsuo Y, Miyamoto T, Yazaki Y, Yahagi K, Yoshida T, Wakabayashi K, Ishii H, Ono M, Kishida A, Kimura T, Sakai T, Morino Y. JCS 2022 Guideline on Perioperative Cardiovascular Assessment and Management for Non-Cardiac Surgery. Circ J 2023; 87:1253-1337. [PMID: 37558469 DOI: 10.1253/circj.cj-22-0609] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/11/2023]
Affiliation(s)
- Eiji Hiraoka
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital
| | | | - Tadao Kubota
- Department of General Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Amane Kozuki
- Division of Cardiology, Osaka Saiseikai Nakatsu Hospital
| | | | | | - Toshiro Shinke
- Division of Cardiology, Showa University School of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, International University of Health and Welfare Narita Hospital
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Taku Inohara
- Department of Cardiovascular Medicine, Keio University Graduate School of Medicine
| | - Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital
| | | | - Yutaka Kondo
- Department of Emergency and Critical Care Medicine, Juntendo University Urayasu Hospital
| | - Yumiko Shimada
- JADECOM Academy NP·NDC Training Center, Japan Association for Development of Community Medicine
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Tomofumi Takaya
- Department of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center
| | - Atsushi Tada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University
| | - Tomohiko Taniguchi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital
| | - Kazuya Nagao
- Department of Cardiology, Osaka Red Cross Hospital
| | - Kenichi Nakazono
- Department of Pharmacy, St. Marianna University Yokohama Seibu Hospital
| | | | | | - Yuichiro Matsuo
- Department of Internal Medicine, Tokyo Bay Urayasu Ichikawa Medical Center
| | | | | | | | | | | | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Tetsuro Sakai
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University
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Gioscia R, Castagno C, Verdoia M, Conti B, Forliti E, Rognoni A. Optimization of the pharmacological therapy in patients with poly-vascular disease: A multidisciplinary approach. World J Cardiol 2023; 15:142-153. [PMID: 37124976 PMCID: PMC10130889 DOI: 10.4330/wjc.v15.i4.142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 04/20/2023] Open
Abstract
The recent shift of the concept of cardiovascular disease as a chronic progressive condition, potentially involving multiple districts, has driven attention to the optimal management of patients with concomitant coronary and peripheral artery disease, representing a subset of patients with an increased risk of events and impaired survival. Recent pharmacological achievements in terms of antithrombotic therapy and lipid-lowering drugs allow multiple therapeutical combinations, thus requiring optimizing the treatment in a tailored fashion according to patients’ risk profiles. Nevertheless, data dedicated to this specific subset of patients are still modest. We summarize currently available strategies and indications for the management of antithrombotic and lipid-lowering drugs in patients with the poly-vascular disease.
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Affiliation(s)
- Rocco Gioscia
- Department of Cardiology, Nuovo Ospedale Degli Infermi, Biella 13900, Italy
| | - Claudio Castagno
- Department of Vascular Surgery, Nuovo Ospedale Degli Infermi, Biella 13900, Italy
| | - Monica Verdoia
- Department of Cardiology, Nuovo Ospedale Degli Infermi, Biella 13900, Italy
| | - Barbara Conti
- Department of Vascular Surgery, Nuovo Ospedale Degli Infermi, Biella 13900, Italy
| | - Enzo Forliti
- Department of Vascular Surgery, Nuovo Ospedale Degli Infermi, Biella 13900, Italy
| | - Andrea Rognoni
- Department of Cardiology, Nuovo Ospedale Degli Infermi, Biella 13900, Italy
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4
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Popova E, Alonso-Coello P, Álvarez-García J, Paniagua-Iglesias P, Rué-Monné M, Vives-Borrás M, Font-Gual A, Gich-Saladich I, Martínez-Bru C, Ordóñez-Llanos J, Carles-Lavila M. Cost-effectiveness of a high-sensitivity cardiac troponin T systematic screening strategy compared with usual care to identify patients with peri-operative myocardial injury after major noncardiac surgery. Eur J Anaesthesiol 2023; 40:179-189. [PMID: 36722187 DOI: 10.1097/eja.0000000000001793] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND About 300 million surgeries are performed worldwide annually and this figure is increasing constantly. Peri-operative myocardial injury (PMI), detected by cardiac troponin (cTn) elevation, is a common cardiac complication of noncardiac surgery, strongly associated with short- and long-term mortality. Without systematic peri-operative cTn screening, most cases of PMI may go undetected. However, little is known about cost effectiveness of a systematic PMI screening strategy with high-sensitivity cardiac troponin T (hs-cTnT) after noncardiac surgery. OBJECTIVE To assess, in patients with high cardiovascular risk, the cost-effectiveness of a systematic screening strategy using a hs-cTnT assay, to identify patients with PMI after major noncardiac surgery, compared with usual care. DESIGN Cost-effectiveness analysis; single centre prospective cohort study. SETTING Spanish University Hospital. PATIENTS From July 2016 to March 2019, we included 1477 consecutive surgical patients aged ≥65 or if <65, with documented history of cardiovascular disease or impaired renal function, who underwent major noncardiac surgery and required at least an overnight hospital stay. We excluded patients aged <65 years without cardiovascular disease, undergoing minor surgery, or with an expected <24 h hospital stays. INTERVENTIONS We conducted a decision-tree analysis, comparing a systematic screening strategy measuring hs-cTnT before surgery, and at the 2nd and 3rd days after surgery vs. a usual care strategy. We considered a third-party payer perspective and the outcomes of both strategies in the short-term (30 days follow-up). Information about costs was expressed in Euros-2021. We calculated the incremental cost-effectiveness ratio (ICER) of the systematic hs-cTnT strategy, defined as the expected cost per any additional PMI detected, and explored the robustness of the model using deterministic and probabilistic sensitivity analysis. MAIN OUTCOME MEASURES ICER of the systematic hs-cTnT screening strategy. RESULTS The ICER was €425 per any additionally detected PMI. The deterministic sensitivity analysis showed that a 15% variation in costs, and a 1% variation in the predictive values, had a minor impact over the ICER, except in case of the negative predictive value of the systematic hs-cTnT screening strategy. Monte Carlo simulations (probabilistic sensitivity analysis) showed that systematic hs-cTnT screening would be cost-effective in 100% of cases with a 'willingness to pay' of €780. CONCLUSIONS Our results suggest that systematic peri-operative PMI screening with hs-cTnT may be cost-effective in the short-term in patients undergoing major noncardiac surgery. Economic evaluations, with a long-term horizon, are still needed. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03438448.
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Affiliation(s)
- Ekaterine Popova
- From the IIB SANT PAU, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain (EP, PA-C, IG-S), Centro Cochrane Iberoamericano, Barcelona, Spain (EP, PA-C), CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain (PA-C, IG-S), Hospital de la Santa Creu i Sant Pau, Department of Cardiology, Barcelona, Spain (JÁ-G, MV-B), Hospital Universitario Ramon y Cajal, Department of Cardiology, Madrid, Spain (JÁ-G), Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares (CIBERCV), Madrid, Spain (JÁ-G), Hospital de la Santa Creu i Sant Pau, Department of Anaesthesia and Pain Management, Barcelona, Spain (PP-I, AF-G), Institut de Recerca Biomèdica de Lleida (IRBLleida), Department of Basic Medical Sciences, Lleida, Spain (MR-M), Research Group in Statistical and Economic Analysis in Health (GRAEES), Lleida, Spain (MR-M), Fundació Institut d'Investigació Sanitària Illes Balears (IdISBa), Department of Cardiology, Palma, Balearic Islands, Spain (MV-B), Hospital de la Santa Creu i Sant Pau, Department of Clinical Epidemiology and Public Health, Barcelona, Spain (IG-S), Hospital de la Santa Creu i Sant Pau, Department of Biochemistry, Barcelona, Spain (CM-B, JO-L), Fundación para la Bioquímica Clínica y Patología Molecular. Barcelona, Spain (JO-L), Universitat Rovira i Virgili, Economy Faculty, Reus, Spain (MC-L), Centro de Investigación en Economía y Sostenibilidad (ECO-SOS), Reus, Spain (MC-L)
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5
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Lee C, Columbo JA, Stone DH, Creager MA, Henkin S. Preoperative evaluation and perioperative management of patients undergoing major vascular surgery. Vasc Med 2022; 27:496-512. [PMID: 36214163 PMCID: PMC9551317 DOI: 10.1177/1358863x221122552] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients undergoing major vascular surgery have an increased risk of perioperative major adverse cardiovascular events (MACE). Accordingly, in this population, it is of particular importance to appropriately risk stratify patients' risk for these complications and optimize risk factors prior to surgical intervention. Comorbidities that portend a higher risk of perioperative MACE include coronary artery disease, heart failure, left-sided valvular heart disease, and significant arrhythmic burden. In this review, we provide a current approach to risk stratification prior to major vascular surgery and describe the strengths and weaknesses of different cardiac risk indices; discuss the role of noninvasive and invasive cardiac testing; and review perioperative pharmacotherapies.
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Affiliation(s)
| | | | | | | | - Stanislav Henkin
- Stanislav Henkin, Heart and Vascular
Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at
Dartmouth, Lebanon, NH 03756, USA.
Twitter: @stanhenkin
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6
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Andrews L, Goldin L, Shen Y, Korwek K, Kleja K, Poland RE, Guy J, Sands KE, Perlin JB. Discontinuation of atorvastatin use in hospital is associated with increased risk of mortality in COVID-19 patients. J Hosp Med 2022; 17:169-175. [PMID: 35504528 PMCID: PMC9088329 DOI: 10.1002/jhm.12789] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/03/2022] [Accepted: 01/18/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Statins are a commonly used class of drugs, and reports have suggested that their use may affect COVID-19 disease severity and mortality risk. OBJECTIVE The purpose of this analysis was to determine the effect of discontinuation of previous atorvastatin therapy in patients hospitalized for COVID-19 on the risk of mortality and ventilation. METHODS Data from 146,413 hospitalized COVID-19 patients were classified according to statin therapy. Home + in hospital atorvastatin use (continuation of therapy); home + no in hospital atorvastatin use (discontinuation of therapy); no home + no in hospital atorvastatin use (no statins). Logistic regression was performed to assess the association between atorvastatin administration and either mortality or use of mechanical ventilation during the encounter. RESULTS Continuous use of atorvastatin (home and in hospital) was associated with a 35% reduction in the odds of mortality compared to patients who received atorvastatin at home but not in hospital (odds ratio [OR]: 0.65, 95% confidence interval [CI]: 0.59-0.72, p < .001). Similarly, the odds of ventilation were lower with continuous atorvastatin therapy (OR: 0.70, 95% CI: 0.64-0.77, p < .001). CONCLUSIONS Discontinuation of previous atorvastatin therapy is associated with worse outcomes for COVID-19 patients. Providers should consider maintaining existing statin therapy for patients with known or suspected previous use.
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Affiliation(s)
- Laura Andrews
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | - Laurel Goldin
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | - Yan Shen
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | - Kimberly Korwek
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | - Kacie Kleja
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
| | | | - Jeffrey Guy
- Clinical Operations GroupHCA HealthcareNashvilleTennesseeUSA
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Jansen-Chaparro S, López-Carmona MD, Cobos-Palacios L, Sanz-Cánovas J, Bernal-López MR, Gómez-Huelgas R. Statins and Peripheral Arterial Disease: A Narrative Review. Front Cardiovasc Med 2021; 8:777016. [PMID: 34881314 PMCID: PMC8645843 DOI: 10.3389/fcvm.2021.777016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/29/2021] [Indexed: 01/22/2023] Open
Abstract
Peripheral arterial disease (PAD) is a highly prevalent atherosclerotic condition. In patients with PAD, the presence of intermittent claudication leads to a deterioration in quality of life. In addition, even in asymptomatic cases, patients with PAD are at high risk of cardiac or cerebrovascular events. Treatment of PAD is based on lifestyle modifications; regular exercise; smoking cessation; and control of cardiovascular risk factors, including hypercholesterolemia. A growing number of studies have shown that statins reduce cardiovascular risk and improve symptoms associated with PAD. Current guidelines recommend the use of statins in all patients with PAD in order to decrease cardiovascular events and mortality. However, the prescribing of statins in patients with PAD is lower than in those with coronary heart disease. This review provides relevant information from the literature that supports the use of statins in patients with PAD and shows their potential benefit in decreasing lower limb complications as well as cardiovascular morbidity and mortality.
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Affiliation(s)
- Sergio Jansen-Chaparro
- Internal Medicine Service, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Málaga (IBIMA), University of Malaga (UMA), Malaga, Spain
| | - María D López-Carmona
- Internal Medicine Service, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Málaga (IBIMA), University of Malaga (UMA), Malaga, Spain
| | - Lidia Cobos-Palacios
- Internal Medicine Service, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Málaga (IBIMA), University of Malaga (UMA), Malaga, Spain
| | - Jaime Sanz-Cánovas
- Internal Medicine Service, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Málaga (IBIMA), University of Malaga (UMA), Malaga, Spain
| | - M Rosa Bernal-López
- Internal Medicine Service, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Málaga (IBIMA), University of Malaga (UMA), Malaga, Spain.,CIBER, Fisiopatología de Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
| | - Ricardo Gómez-Huelgas
- Internal Medicine Service, Regional University Hospital of Malaga, Instituto de Investigación Biomédica de Málaga (IBIMA), University of Malaga (UMA), Malaga, Spain.,CIBER, Fisiopatología de Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain
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8
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Allar BG, Swerdlow NJ, de Guerre LEVM, Dansey KD, Li C, Wang GJ, Patel VI, Schermerhorn ML. Preoperative statin therapy is associated with higher 5-year survival after thoracic endovascular aortic repair. J Vasc Surg 2021; 74:1996-2005. [PMID: 34182025 DOI: 10.1016/j.jvs.2021.05.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Statin use is associated with higher long-term survival after abdominal aortic aneurysm repair. However, the association between statin use and survival after thoracic endovascular aortic repair (TEVAR) has not been established. METHODS We performed a review of prospectively collected data of all patients who had undergone TEVAR in the Vascular Quality Initiative between 2014 and 2020. We excluded patients aged <18 years, those who had presented with trauma, and those who had received custom-manufactured or physician-modified devices. We evaluated the association between preoperative statin therapy and in-hospital mortality and complications and 5-year mortality. We also analyzed the trend of preoperative statin use in elective cases for the previous 7 years. To account for nonrandom assignment to treatment, we used propensity score matching of patient characteristics, comorbidities, pathology, and urgency for preoperative statin use. We used logistic regression and Cox regression for the short-term and 5-year outcomes, respectively. RESULTS Of 6266 patients who had undergone TEVAR and met the inclusion criteria, 3331 (53%) patients had been taking a statin preoperatively, including 1148 of 2267 (64%) treated for aneurysmal disease. After propensity score matching, 1875 patients were in each cohort. Preoperative statin use was associated with lower rates of any perioperative complication (16.7% vs 19.6%; odds ratio, 0.82; 95% confidence interval [CI] 0.69-0.97; P = .022). Overall, preoperative statin use was also associated with lower 5-year mortality (18.8% vs 24.5%; hazard ratio [HR], 0.74; 95% CI, 0.63-0.89; P = .001). When stratified by urgency, preoperative statin use was associated with lower 5-year mortality after elective TEVAR (14.9% vs 22.4%; HR, 0.62; 95% CI, 0.49-0.79; P < .001) but not after urgent or emergent TEVAR (27.4% vs 29.1%; HR, 0.89; 95% CI, 0.70-1.14; P = .37). When stratified by pathology, preoperative statin use was associated with significantly lower 5-year mortality for patients with aneurysms (HR, 0.63; 95% CI, 0.48-0.83; P = .001). Although the mortality was also lower for patients with dissection and "other" pathology, these differences did not reach statistical significance. Between 2014 and 2019, a significant increase had occurred in statin use among patients undergoing elective TEVAR, from 56% in 2014 to 64% in 2019 (P = .007). CONCLUSIONS Preoperative statin therapy is associated with lower perioperative complication rates and 5-year mortality for patients undergoing TEVAR. All patients with known thoracic aortic pathology should receive statin therapy unless contraindications for the drug are present. For patients undergoing elective TEVAR, the statin prescription percentage should be considered a quality metric, and further implementation research should occur to improve preoperative statin use.
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Affiliation(s)
- Benjamin G Allar
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Nicholas J Swerdlow
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Livia E V M de Guerre
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Kirsten D Dansey
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Chun Li
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, Pa
| | - Virendra I Patel
- Division of Cardiac, Thoracic, and Vascular Surgery, New York-Presbyterian/Columbia University Medical Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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9
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Giannopoulos S, Armstrong EJ. Clinical considerations after endovascular therapy of peripheral artery disease. Expert Rev Cardiovasc Ther 2021; 19:369-378. [PMID: 33870848 DOI: 10.1080/14779072.2021.1914590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction: Patients with peripheral artery disease (PAD) are at higher risk for all-cause mortality, driven by increased cardiovascular mortality rates. In this manuscript we review the literature on guideline-recommended therapies and discuss the major clinical considerations after endovascular therapy of PAD.Areas covered: Current guidelines recommend smoking cessation, aspirin, statin, and renin-angiotensin system inhibitors in order to reduce the risk of cardiovascular and limb-related adverse events. Nonetheless, studies have shown that patients with PAD are undertreated with these important medical therapies. Additionally, there is lack in evidence regarding the most optimal follow up imaging approach for early detection of disease recurrence and re-intervention among patients undergoing endovascular therapy for PAD. We also describe the benefits of supervised walking exercise for patients with PAD that undergo revascularization procedures and are fit for such interventions.Expert opinion: Adherence to guideline recommended medical therapy is crucial for improved outcomes in PAD management. Systematic assessment of risk-reduction interventions could help increase adherence to clinically beneficial interventions and improve the overall prognosis of patients with PAD undergoing revascularization procedures. Additionally, optimization of current follow up protocols is needed, with the optimal goal to develop standardized cost-effective algorithms regarding early detection of disease recurrence and re-intervention.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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10
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Giannopoulos S, Armstrong EJ. Medical therapy for cardiovascular and limb-related risk reduction in critical limb ischemia. Vasc Med 2021; 26:210-224. [PMID: 33587692 DOI: 10.1177/1358863x20987612] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Critical limb ischemia (CLI) constitutes the most advanced form of peripheral artery disease (PAD) and is characterized by ischemic rest pain, tissue loss and/or gangrene. Optimized medical care and risk factor modification in addition to revascularization could reduce the incidence of cardiovascular events and major adverse limb events, improving patients' quality of life and promising higher survival rates. Adequate adherence to cardioprotective medications, including antithrombotic therapy (e.g., antiplatelets, anticoagulants), cholesterol-lowering agents (e.g., statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors), angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and smoking cessation should be strongly encouraged for patients with CLI. This review examines these guideline-recommended therapies in terms of cardiovascular and limb-related risk reduction in patients with CLI.
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Affiliation(s)
- Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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11
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Jang SH, Kwon DH, Han MK, Park H, Sohn SI, Choi H, Hong JH. Impact of statin pretreatment on the complications of carotid stenting in asymptomatic patients: observational study. BMC Neurol 2021; 21:75. [PMID: 33588788 PMCID: PMC7883458 DOI: 10.1186/s12883-021-02104-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 02/02/2021] [Indexed: 11/10/2022] Open
Abstract
Background Carotid stenosis is a known risk factor for ischemic stroke, and carotid artery stenting is an effective preventive procedure. However, the stroke risk reduction for asymptomatic patients is small. Therefore, it is important to reduce the risk of complications, particularly in asymptomatic carotid stenosis. Statins are known to reduce the overall risk of periprocedural complications, although there is a lack of data focusing on asymptomatic patients. We aimed to investigate whether different doses of statin pretreatment can reduce periprocedural complications of carotid artery stenting (CAS) in patients with asymptomatic carotid artery stenosis. Methods Between July 2003 and June 2013, 276 consecutive patients received CAS for asymptomatic carotid stenosis. Periprocedural complications included the outcome of stroke, myocardial infarction, or death within 30 days of CAS. Statin pretreatment was categorized as no-statin (n = 87, 31.5%), standard-dose (< 40 mg, n = 139, 50.4%), and high-dose statin (≥40 mg, n = 50, 18.1%) according to the atorvastatin equivalent dose. The Cochran-Armitage (CA) trend test was performed to investigate the association of periprocedural complications with statin dose. Results The overall periprocedural complication rate was 3.3%. There was no significant difference in the risk of periprocedural complications between the three groups (no statin: n = 3 [3.4%]; standard-dose: n = 4 [2.9%]; high-dose n = 2 [4.0%] p = 0.923). The CA trend test did not demonstrate a trend in the proportion of periprocedural complications across increasing statin equivalent doses (p = 0.919). Conclusions Statin pretreatment before CAS showed neither absolute nor dose-dependent effects against periprocedural complications in asymptomatic patients undergoing CAS. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02104-z.
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Affiliation(s)
- Seong Hwa Jang
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Doo Hyuk Kwon
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University School of Medicine, Seongnam, South Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea
| | - Huimahn Choi
- Department of Neurology and Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, South Korea.
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Lin F, Wang H, Ding W, Chen G, Zhang Z. Atherectomy plus drug-coated balloon versus drug-coated balloon only for treatment of femoropopliteal artery lesions: A systematic review and meta-analysis. Vascular 2021; 29:883-896. [PMID: 33478353 DOI: 10.1177/1708538120985732] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To compare the safety and efficiency of atherectomy plus drug-coated balloon with drug-coated balloon only for the treatment of femoropopliteal artery lesions. METHODS This systematic review and meta-analysis was performed and reported following the requirement of the PRISMA. EMBASE, MEDLINE, and Cochrane library were queried from January 2000 to June 2020 to identify eligible literature. The modified Downs and Black checklist was used to assess the quality of included studies. Outcome measures included bail-out stenting, distal embolization, perforation, hematoma, primary patency at 12 months, target lesion revascularization at 12 months, leg amputation at 12 months, and mortality at 12 months. We used DerSimonian and Laird random-effects model to pool the dichotomous data on risk ratio (RR) with 95% confidence intervals (CIs) from each study to obtain an overall estimate for major outcomes. Subgroup analysis and sensitivity analyses were conducted. RESULTS Six studies (two randomized controlled trials and four retrospective cohort studies) with 470 patients were included. Atherectomy plus drug-coated balloon group was associated with lower rates of bail-out stenting (RR: 0.49, 95%CI: 0.34-0.71, P < 0.001). There was no significant difference between two groups in terms of distal embolization (RR: 2.06, 95%CI: 0.51-8.38, P = 0.31), perforation (RR: 2.04, 95%CI: 0.43-9.71, P = 0.37), hematoma (RR: 1.75, 95%CI: 0.43-7.09, P = 0.43), primary patency at 12 months (1.09, 95%CI: 0.98-1.21, P = 0.12), target lesion revascularization at 12 months (RR: 0.68, 95%CI: 0.41-1.14, P = 0.15), leg amputations at 12 months (RR: 0.54, 95%CI: 0.13-2.23, P = 0.39), mortality at 12 months (RR: 2.18, 95%CI: 0.71-6.64, P = 0.17). Sensitivity analysis had no effect on our findings. CONCLUSIONS The combination of atherectomy and drug-coated balloon was safe and effective in the treatment of femoropopliteal artery lesions, with lower incidence of bail-out stenting compared with drug-coated balloon only.
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Affiliation(s)
- Feng Lin
- Department of Vascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Haoran Wang
- Department of Vascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wenjie Ding
- Department of Vascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Gan Chen
- Department of Vascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhigong Zhang
- Department of Vascular Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Essa H, Torella F, Lip GYH. Current and emerging drug treatment strategies for peripheral arterial disease. Expert Opin Pharmacother 2020; 21:1603-1616. [DOI: 10.1080/14656566.2020.1774556] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital , Liverpool, UK
| | - Francesco Torella
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital , Liverpool, UK
- Liverpool Vascular and Endovascular Service, Royal Liverpool University Hospital, Liverpool, UK
- School of Physical Sciences, University of Liverpool , UK
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital , Liverpool, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
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O'Donnell TFX, Carpenter JP, Lane JS, Trani J, Hussain S, Healey C, Malas MB, Schermerhorn ML. Endovascular Aneurysm Sealing is Associated with Higher Medium-Term Survival than Traditional EVAR. Ann Vasc Surg 2020; 63:145-154. [PMID: 31629124 PMCID: PMC7012730 DOI: 10.1016/j.avsg.2019.08.094] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/29/2019] [Accepted: 08/29/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Endovascular aneurysm repair (EVAR) is the dominant treatment modality for abdominal aortic aneurysm (AAA). Periprocedural risks are low, and cardiovascular events are the principle determinants of long-term survival. Recently, the concept of endovascular aneurysm sealing (EVAS) has been introduced into clinical investigation. In previous cohort studies, EVAS has been associated with a lower all-cause mortality than expected despite device issues. We used a propensity weighted approach to investigate whether EVAS was associated with lower all-cause mortality after aneurysm repair. METHODS We compared 333 patients in the Nellix United States Investigational Device Exemption trial to 15,431 controls from the Vascular Quality Initiative between 2014 and 2016 after applying the exclusion criteria from the investigational device exemption (hemodialysis, creatinine > 2.0 mg/dL, or rupture). We calculated propensity scores and applied inverse probability weighting to compare risk adjusted medium-term survival using Kaplan-Meier and Cox regression. RESULTS After weighting, patients treated with the Nellix EVAS system experienced higher 3-year survival than controls from the Vascular Quality Initiative (93% vs. 88%, respectively). This corresponded to a 41% lower risk of mortality for EVAS compared with EVAR (HR 0.59 [0.38-0.92], P = 0.02). Subgroup analysis demonstrated that the association between EVAS and higher survival was strongest in the subgroup of patients with aneurysms over 5.5 cm (P for interaction < 0.001). In this subgroup, EVAS patients experienced half the rate of mortality as those patients treated with EVAR, with 3-year survival of 92% compared with 86% (HR 0.5 [0.3-0.9], P = 0.02). CONCLUSIONS In this select group of patients, EVAS was associated with higher medium-term survival than traditional EVAR. Although issues with the device have recently surfaced, this exploratory analysis shows that the concept of sac sealing may hold promise. Further study is needed to confirm this finding and determine whether EVAS is associated with lower rates of cardiovascular events.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Jeffrey P Carpenter
- Division of Vascular Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - John S Lane
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA; Division of Vascular Surgery, San Diego VA Hospital, San Diego CA
| | - Jose Trani
- Division of Vascular Surgery, Cooper Medical School of Rowan University, Camden, NJ
| | - Sajjad Hussain
- Division of Vascular Surgery, St. Vincent's Hospital, Indianapolis, IN
| | | | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, University of California San Diego, San Diego, CA
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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Karavias D, Thomas P, Koh A, Irving G, Navarro AP, Cameron IC, Gomez D. Statin therapy does not influence the outcome of patients undergoing surgery for pancreatic cancer. ANZ J Surg 2019; 90:1671-1676. [PMID: 31845479 DOI: 10.1111/ans.15600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/22/2019] [Accepted: 11/11/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recently, statins have been associated with improved survival in certain cancers. The aim of this study was to evaluate the impact of statins on the outcome of patients undergoing surgery for pancreatic cancer. In addition, the effect of statins on the histopathological characteristics of the disease was assessed. METHODS A retrospective review of the prospectively maintained hepato-pancreatico-biliary database was performed and patients with pancreatic cancer who underwent surgery between January 2014 and December 2017 were included. Statistical analysis was performed to assess the impact of statins on histopathological characteristics and survival outcome. RESULTS A total of 151 patients were included, of whom 71 underwent pancreatic resections and 80 underwent trial dissection and bypass procedures. In the operated group, 20 patients were on statin therapy preoperatively. With respect to disease-free survival, tumour size (P = 0.023) and lymphatic invasion (P = 0.015) were significant variables on univariate analysis. Gender (P = 0.022), adjuvant chemotherapy (P < 0.001), lymphatic invasion (P = 0.021) and tumour size (P = 0.041) were significant variables on univariate analysis with respect to overall survival. Multivariate analysis identified adjuvant chemotherapy as the only independent predictor of overall survival (P < 0.001). No correlations between the use of statins and the histopathological characteristics were identified. CONCLUSION Adjuvant chemotherapy is an independent predictor of overall survival in patients undergoing surgery for pancreatic cancer. Statin therapy does not influence survival outcomes and histopathological characteristics following surgery for pancreatic cancer.
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Affiliation(s)
- Dimitrios Karavias
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Paul Thomas
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amanda Koh
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Glen Irving
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alex P Navarro
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iain C Cameron
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Dhanny Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK.,NIHR Nottingham Digestive Disease Biomedical Research Unit, The University of Nottingham, Nottingham, UK
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Abstract
PURPOSE OF REVIEW The effects of statin loading before, during or after vascular interventions on cardiovascular and renal outcomes are discussed. Furthermore, the selection of optimal statin type and dose, according to current evidence or guidelines, is considered. The importance of treating statin intolerance and avoiding statin discontinuation is also discussed. RECENT FINDINGS Statin loading has been shown to beneficially affect cardiovascular outcomes, total mortality and/or contrast-induced acute kidney injury, in patients undergoing vascular procedures such as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), carotid endarterectomy (CEA), carotid artery stenting, endovascular aneurysm repair, open abdominal aortic aneurysms (AAA) repair and lower extremities vascular interventions. High-dose statin pretreatment is recommended for PCI and CABG according to current guidelines. Statin discontinuation should be avoided during acute cardiovascular events and vascular interventions; adequate measures should be implemented to overcome statin intolerance. SUMMARY Statin loading is an important clinical issue in patients with cardiac and noncardiac vascular diseases, including carotid artery disease, peripheral artery disease and AAA, undergoing vascular interventions. Cardiologists and vascular surgeons should be aware of current evidence and implement guidelines in relation to statin loading, discontinuation and intolerance.
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Abstract
In this review, we discuss clinical evidence-based data regarding the potential benefit of statin therapy in the perioperative period of non-cardiac surgery. Results from meta-analyses of prospective observational studies have provided conflicting evidence. Moreover, comparison among studies is complicated by varying data sources, outcome definitions, types of surgery, and preoperative versus perioperative statin therapy. However, results of two recent large prospective cohort studies showed that statin use on the day of or the day after non-cardiac surgery (or both) is associated with lower 30-day all-cause mortality and reduction in a variety of postoperative complications, predominantly cardiac, compared with non-use during this period. There is a paucity of data from randomized controlled trials assessing the benefit of statin therapy in non-cardiac surgery. No randomized controlled trials have shown that initiating a statin in statin-naïve patients may reduce the risk of cardiovascular complications in non-cardiac surgeries. One randomized clinical trial demonstrated that the use of a preoperative statin in patients with stable coronary heart disease treated with long-term statin therapy had a significant reduction in the incidence of myocardial necrosis and major adverse cardiovascular events after non-cardiac surgery. In conclusion, it is important that all health-care professionals involved in the care of the surgical patient emphasize the need to resume statin therapy, particularly in patients with established atherosclerotic cardiovascular disease. However, initiating a statin in statin-naïve patients undergoing non-cardiac surgery needs more evidence-based data.
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Affiliation(s)
- Reza Mohebi
- Department of Medicine (Cardiology), Icahn school of Medicine at Mount Sinai, New York, 10029, USA
| | - Robert Rosenson
- Department of Medicine (Cardiology), Icahn school of Medicine at Mount Sinai, New York, 10029, USA
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Association between statin use and perioperative mortality after aortobifemoral bypass in patients with aortoiliac occlusive disease. J Vasc Surg 2019; 70:509-515. [PMID: 30837182 DOI: 10.1016/j.jvs.2018.10.120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 10/23/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The benefit of statins in reducing perioperative cardiovascular events in patients undergoing suprainguinal bypass is still controversial. The purpose of this study was to evaluate the association between statin use and perioperative mortality in patients undergoing aortobifemoral bypass (ABFB) for aortoiliac occlusive disease. METHODS We retrospectively analyzed all patients who had ABFB in the American College of Surgeons National Surgical Quality Improvement Program data set from 2011 to 2016. Univariable (t-test, χ2 test, or Fisher exact test) and multivariable logistic regression analyses were used to compare patients' characteristics and the primary outcome (30-day mortality) between statin users and nonstatin users. Propensity score matching between statin users and nonusers was also performed on the basis of variables that were different between the two groups. RESULTS A total of 4445 patients underwent ABFB. Of those, 3032 (68.2%) were taking statins. Compared with nonstatin users, statins users were older (median [interquartile range], 67 years [59-74 years] vs 63 years [56-72 years]; P < .01) and more likely to be diabetic (31% vs 16%) and hypertensive (84% vs 63%) and to have a history of chronic obstructive pulmonary disease (20% vs 17%; all P < .05). Statin users had lower rates of 30-day mortality (3.4% vs 4.7%; P = .03) and renal complications (2.5% vs 3.7%; P = .04) compared with nonstatin users. After adjustment for patients' demographics (age, sex, race), comorbidities (diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, dialysis, bleeding disorder), smoking, clinical presentation (claudication vs critical limb ischemia), and elective surgery status, statin use was associated with 32% reduction in 30-day mortality (odds ratio, 0.68; 95% confidence interval, 0.47-0.96; P = .03). Propensity score matching showed similar results (odds ratio, 0.63; 95% confidence interval, 0.41-0.95; P = .03). CONCLUSIONS This is the largest study to date demonstrating an association between preoperative statin use and lower 30-day mortality after ABFB for aortoiliac occlusive disease. This study highlights an area of potential quality improvement as one-third of the patients undergoing this procedure are not receiving statins.
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Rizwan M, Faateh M, Dakour-Aridi H, Nejim B, Alshwaily W, Malas MB. Statins reduce mortality and failure to rescue after carotid artery stenting. J Vasc Surg 2019; 69:112-119. [DOI: 10.1016/j.jvs.2018.03.424] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/08/2018] [Indexed: 11/15/2022]
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Hajibandeh S, Hajibandeh S, Antoniou SA, Torella F, Antoniou GA. Effect of beta-blockers on perioperative outcomes in vascular and endovascular surgery: a systematic review and meta-analysis. Br J Anaesth 2018; 118:11-21. [PMID: 28039238 DOI: 10.1093/bja/aew380] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND To investigate the role of perioperative beta-blocker use in vascular and endovascular surgery. METHODS We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards. The review protocol was registered with International Prospective Register of Systematic Reviews (registration number:CRD42016038111). We searched electronic databases to identify all randomized controlled trials and observational studies investigating outcomes of patients undergoing vascular and endovascular surgery with or without perioperative beta blockade. We used the Cochrane tool and the Newcastle-Ottawa scale to assess the risk of bias of trials and observational studies, respectively. Random-effects models were applied to calculate pooled outcome data. RESULTS We identified three randomized trials, five retrospective cohort studies, and three prospective cohort studies, enrolling a total of 32,602 patients. Our analyses indicated that perioperative use of beta-blockers did not reduce the risk of all-cause mortality [odds ratio (OR) 1.10, 95% confidence interval (CI) 0.59-2.04, P = 0.77], cardiac mortality (OR 2.62, 95% CI 0.86-8.05, P = 0.09), myocardial infarction (OR 0.89, 95% CI 0.59-1.35, P = 0.58), unstable angina (OR 1.34, 95% CI 0.41- 4.38, P = 0.63), stroke (OR 2.45, 95% CI 0.89-6.75, P = 0.08), arrhythmias (OR 0.76, 95% CI 0.41-1.43, P = 0.40), congestive heart failure (OR 1.12, 95% CI 0.77-1.63, P = 0.56), renal failure (OR 1.48, 95% CI 0.90-2.45, P = 0.13), composite cardiovascular events (OR 0.88, 95% CI 0.55-1.40, P = 0.58), rehospitalisation (OR 0.86, 95% CI 0.48-1.52, P = 0.60), and reoperation (OR 1.17, 95% CI 0.42-3.27, P = 0.77) in vascular surgery. CONCLUSIONS Beta-blockers do not improve perioperative outcomes in vascular and endovascular surgery.
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Affiliation(s)
- S Hajibandeh
- Department of General Surgery, Royal Blackburn Hospital, Blackburn, UK
| | - S Hajibandeh
- Department of General Surgery, Royal Blackburn Hospital, Blackburn, UK
| | - S A Antoniou
- Department of General Surgery, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - F Torella
- Department of Mathematical Sciences, School of Physical Sciences, University of Liverpool, Liverpool, UK
| | - G A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, UK
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Juszczak MT, Taib B, Rai J, Iazzolino L, Carroll N, Antoniou GA, Neequaye S, Torella F. Total psoas area predicts medium-term mortality after lower limb revascularization. J Vasc Surg 2018; 68:1114-1125.e1. [DOI: 10.1016/j.jvs.2018.01.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/16/2018] [Indexed: 01/22/2023]
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Texakalidis P, Giannopoulos S, Jonnalagadda AK, Chitale RV, Jabbour P, Armstrong EJ, Schwartz GG, Kokkinidis DG. Preoperative Use of Statins in Carotid Artery Stenting: A Systematic Review and Meta-analysis. J Endovasc Ther 2018; 25:624-631. [PMID: 30101624 DOI: 10.1177/1526602818794030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To determine through meta-analysis whether administration of statins before carotid artery stenting (CAS) is associated with fewer periprocedural adverse events. METHODS All randomized and observational English-language studies of periprocedural statin administration prior to CAS that reported the outcomes of interest (stroke, transient ischemic attack, myocardial infarction, and death at 30 days) were included in a random-effects meta-analysis. The I2 statistic was used to assess heterogeneity. Meta-regression analysis was performed to determine whether an association of statin treatment with risk of outcome events was influenced by other trial-level baseline characteristics of statin-treated and untreated patients. RESULTS Eleven studies comprising 4088 patients were included. Patients who received statins prior to CAS had a significantly lower risk of stroke (OR 0.39, 95% CI 0.27 to 0.58, p<0.01; I2=0%) and death (OR 0.30, 95% CI 0.10 to 0.96, p=0.042; I2=0%). Statin use was not associated with a reduced risk of transient ischemic attack or myocardial infarction. In meta-regression analysis, other trial-level baseline characteristics had no significant influence on the association of statin treatment with death or stroke. CONCLUSION Statin therapy prior to CAS is associated with decreased risk of perioperative stroke and death without any effect on the rates of transient ischemic attack or myocardial infarction.
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Affiliation(s)
| | | | - Anil K Jonnalagadda
- 3 Division of Cardiology, Medstar Washington Hospital Center, Washington, DC, USA
| | - Rohan V Chitale
- 4 Department of Neurosurgery, Vanderbilt University Hospital, Nashville, TN, USA
| | - Pascal Jabbour
- 5 Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ehrin J Armstrong
- 6 Division of Cardiology, Denver VA Medical Center, University of Colorado, Denver, CO, USA
| | - Gregory G Schwartz
- 6 Division of Cardiology, Denver VA Medical Center, University of Colorado, Denver, CO, USA
| | - Damianos G Kokkinidis
- 7 Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Outcome of Carotid Artery Endarterectomy in Statin Users versus Statin-Naïve Patients: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 116:444-450.e1. [DOI: 10.1016/j.wneu.2018.05.160] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 11/22/2022]
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O'Donnell TFX, Deery SE, Shean KE, Mittleman MA, Darling JD, Eslami MH, DeMartino RR, Schermerhorn ML. Statin therapy is associated with higher long-term but not perioperative survival after abdominal aortic aneurysm repair. J Vasc Surg 2018; 68:392-399. [PMID: 29580855 PMCID: PMC6057816 DOI: 10.1016/j.jvs.2017.11.084] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 11/11/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Although preoperative and perioperative statin therapy improves postoperative outcomes in several populations, few data examine its association with survival after abdominal aortic aneurysm (AAA) repair. In addition, no data exist regarding the benefits of starting statins in patients with AAA not currently taking them. METHODS We performed a registry-based study of all patients undergoing repair of AAAs in the Vascular Quality Initiative between 2003 and 2017 without documented statin intolerance. In our primary analysis, we evaluated the association between preoperative statin therapy and long-term mortality, 30-day mortality, and in-hospital myocardial infarction and stroke. As a secondary analysis, we studied the cohort of patients not taking a statin preoperatively and compared their long-term mortality on the basis of whether they were discharged on a statin. To account for nonrandom assignment to treatment, we constructed propensity scores and applied inverse probability weighting. RESULTS We identified 40,452 AAA repairs, of which 37,950 fit our entry criteria (29,257 endovascular and 8693 open). Overall, 25,997 patients (69%) were taking a statin preoperatively, with patients undergoing endovascular aneurysm repair more frequently taking a statin than those undergoing open repair (69% compared with 66%; P < .001). After propensity weighting, preoperative statin therapy was not associated with 30-day death or in-hospital stroke or myocardial infarction. However, patients taking statins preoperatively experienced higher adjusted 1-year (94% vs 90%) and 5-year (85% vs 81%) survival from the date of surgery compared with those who were not (P < .001 overall), although subgroup analysis showed that this applied only to intact or symptomatic aneurysms. Of the 11,941 patients not taking a statin preoperatively and discharged alive, 2910 (24%) started on a statin before discharge. In our secondary analysis of the subset of patients not taking statins preoperatively, those initiated on a statin before discharge experienced higher survival at 1 year (94% vs 91%) and 5 years (89% vs 81%; P < .001 overall) than those who remained off statin therapy, with the greatest absolute long-term survival difference in patients with rupture (87% vs 62%; P < .001 overall). CONCLUSIONS Preoperative statin therapy is associated with higher long-term survival but not perioperative mortality and morbidity in patients undergoing AAA repair, and initiating statin therapy in previously statin-naive patients is associated with markedly higher survival. All patients with AAAs without contraindications should receive statin therapy. In patients not taking a statin at the time of AAA repair, clinicians should consider initiating one before discharge.
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Affiliation(s)
- Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Katie E Shean
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass; Department of Surgery, St. Elizabeth's Medical Center, Boston, Mass
| | - Murray A Mittleman
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Mass; Cardiovascular Epidemiology Research Unit, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Jeremy D Darling
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | | | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, Mass.
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Ma B, Sun J, Diao S, Zheng B, Li H. Effects of perioperative statins on patient outcomes after noncardiac surgery: a meta-analysis. Ann Med 2018; 50:402-409. [PMID: 29741972 DOI: 10.1080/07853890.2018.1471217] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Cardiovascular complications are strongly correlated with a higher risk of mortality during follow-up after noncardiac surgery. However, controversy remains regarding whether perioperative administration of hydroxymethylglutaryl-CoA reductase inhibitors (statins) has a beneficial effect on patient outcomes. OBJECTIVE We performed a meta-analysis to validate the hypothesis that perioperative statins improve patient outcomes after noncardiac surgery. METHODS Electronic databases (PubMed, Web of Science, EMBASE, and the Cochrane Library) were searched for randomized controlled trials (RCTs) published up to 10 November 2017. RCTs were eligible for inclusion if they compared perioperative statin treatment with control treatment in patients scheduled for noncardiac surgery and reported data pertaining to clinical outcomes. RESULTS Twelve RCTs involving 4707 patients (2371 in the perioperative statin group and 2336 in the control group) were ultimately included in this meta-analysis. The incidences of postoperative myocardial infarction, composite of death/myocardial infarction/stroke and new cases of atrial fibrillation were all lower in patients treated with statins than in control group patients, as shown by the fixed-effects model (odds ratio (OR) = 0.460, 95% confidence interval (CI) = 0.324-0.653, p = 0 for myocardial infarction; OR = 0.617, 95% CI = 0.476-0.801, p = 0 for composite of death/myocardial infarction/stroke; OR = 0.406, 95% CI = 0.247-0.666, p = 0 for new atrial fibrillation). No significant differences in the incidences of stroke or transient ischemic attack, all-cause mortality and cardiovascular mortality were observed between the statin and control arms. CONCLUSIONS This meta-analysis supports the hypothesis that perioperative statins effectively reduce the incidences of postoperative myocardial infarction, composite of death/myocardial infarction/stroke and new cases of atrial fibrillation in patients undergoing noncardiac surgery. Key Messages Cardiovascular complications are strongly correlated with a higher risk of mortality during follow-up after noncardiac surgery. We performed a meta-analysis to confirm the hypothesis that perioperative statins improve patient outcomes after noncardiac surgery.
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Affiliation(s)
- Baoxin Ma
- a Department of Cardiology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
| | - Jingwu Sun
- a Department of Cardiology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
| | - Shuling Diao
- a Department of Cardiology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
| | - Bo Zheng
- a Department of Cardiology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
| | - Hua Li
- b Department of Oncology , The Affiliated Hospital of Binzhou Medical University , Binzhou , Shandong , China
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Aboyans V, Kakisis Y. Myocardial Injury After Non-cardiac Surgery: What this "MINS" for the Vascular Surgeon? Eur J Vasc Endovasc Surg 2018; 56:161-162. [PMID: 30100017 DOI: 10.1016/j.ejvs.2018.06.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 06/17/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, Limoges, France.
| | - Yannis Kakisis
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
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Yu W, Wang B, Zhan B, Li Q, Li Y, Zhu Z, Yan Z. Statin therapy improved long-term prognosis in patients with major non-cardiac vascular surgeries: a systematic review and meta-analysis. Vascul Pharmacol 2018; 109:1-16. [PMID: 29953967 DOI: 10.1016/j.vph.2018.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/08/2018] [Accepted: 06/21/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To investigate whether statin intervention will improve the long-term prognosis of patients undergoing major non-cardiac vascular surgeries. METHODS Major database searches for clinical trials enrolling patients undergoing major non-cardiac vascular surgeries, including lower limb revascularization, carotid artery surgeries, arteriovenous fistula, and aortic surgeries, were performed. Subgroup analyses, stratified by surgical types or study types, were employed to obtain statistical results regarding survival, patency rates, amputation, and cardiovascular and stroke events. Odds ratio (ORs) and 95% confidence intervals (CIs) were calculated by Review Manager 5.3. Sensitivity analysis, publication bias and meta-regression were conducted by Stata 14.0. RESULTS In total, 34 observational studies, 8 prospective cohort studies and 4 randomized controlled clinical trials (RCTs) were enrolled in the present analysis. It was demonstrated that statin usage improved all-cause mortality in lower limb, carotid, aortic and mixed types of vascular surgery subgroups compared with those in which statins were not used. Additionally, the employment of statins efficiently enhanced the primary and secondary patency rates and significantly decreased the amputation rates in the lower limb revascularization subgroup. Furthermore, for other complications, statin intervention decreased cardiovascular events in mixed types of vascular surgeries and stroke incidence in the carotid surgery subgroup. No significant publication bias was observed. The meta-regression results showed that the morbidity of cardiovascular disease or the use of aspirin might affect the overall estimates in several subgroups. CONCLUSIONS This meta-analysis demonstrated that statin therapy was associated with improved survival rates and patency rates and with reduced cardiovascular or stroke morbidities in patients who underwent non-cardiac vascular surgeries.
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Affiliation(s)
- Wenpei Yu
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China; The Thirteenth People's Hospital of Chongqing, The Chongqing Geriatric Hospital, Chongqing 400053, China
| | - Bin Wang
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China; Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, Beijing Key Laboratory of Kidney Disease, National Clinical Research Center for Kidney Diseases, Fuxing Road 28, Beijing 100853, China
| | - Bin Zhan
- The Thirteenth People's Hospital of Chongqing, The Chongqing Geriatric Hospital, Chongqing 400053, China
| | - Qiang Li
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Yingsha Li
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Zhiming Zhu
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China
| | - Zhencheng Yan
- The Center for Hypertension and Metabolic Diseases, Department of Hypertension and Endocrinology, Daping Hospital, Third Military Medical University, Chongqing Institute of Hypertension, Chongqing 400042, China.
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Statin use is not associated with improved 30-day survival in patients undergoing surgery for colorectal cancer. Int J Colorectal Dis 2018; 33:199-207. [PMID: 29270783 DOI: 10.1007/s00384-017-2947-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Besides the lipid-lowering properties, statins are thought to have anti-inflammatory effects and it has been shown that statins directly attenuate the inflammatory stress response after surgical trauma. The aim of the study was to examine the association between preoperative statin use and 30-day mortality as well as postoperative complications after curative-intended surgery for colorectal cancer. METHODS The study was a Danish nationwide register-based observational study. A total of 29,352 patients undergoing surgery for colorectal cancer between January 1, 2003, and December 31, 2012, were included in the study. At the time of surgery, 5961 were registered as statin users. The outcomes were 30-day mortality and risk of postoperative complications. RESULTS The adjusted hazard ratio of 30-day mortality was 0.91 (95 CI 0.80-1.04, P = 0.16) among statin users compared with the non-statin group. There was no difference between the two groups regarding the risk of infectious complications (sepsis, anastomotic leakage, pneumonia) (odds ratio 0.95, 95% CI 0.86-1.05, P = 0.31). For other postoperative complications (cardiovascular events, stroke, renal failure, respiratory insufficiency, and thromboembolic events), there was no significant difference between the two groups (odds ratio 0.89, 95% CI 0.78-1.01, P = 0.06). CONCLUSION The study did not show an improved 30-day survival after surgery for colorectal cancer in patients treated with statins in the year preceding surgery. No overall association with the risk of postoperative complications was shown.
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Abstract
PURPOSE OF REVIEW Coronary artery event includes acute coronary syndrome (ACS), percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) surgery. Following such an event, risk of noncardiac surgery is increased. Of major concern is what can make this surgery safer? RECENT FINDINGS High functional capacity improves cardiovascular (CV) risk; at least 4.0 metabolic equivalents (METs) on stress test are favorable. Risk scores can suggest need for further evaluation. Coronary angiography prior to surgery usually is not indicated since revascularization shows disappointing CV risk reduction results. Due to high association of peripheral arterial disease (PAD) with coronary artery disease (CAD), low ankle-brachial index (ABI) indicates increased CV risk. New perioperative beta blockade has shown disappointing benefit, but if ongoing should be continued. De novo perioperative beta blockade is for the highest CV risk patient undergoing noncardiac vascular surgery. Good evidence supports CV risk reduction from new or existing statin in the perioperative period, especially for the diabetic. Diabetics should also be on an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) secondarily, during the perioperative period to decrease 30-day perioperative mortality. Optimal timing of elective noncardiac surgery following a coronary artery event appears to be 180 days with CV risk decreased by a statin and an ACEI or an ARB.
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Affiliation(s)
- Thomas F Whayne
- Gill Heart and Vascular Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA.
| | - Sibu P Saha
- Gill Heart and Vascular Institute, University of Kentucky, 326 Wethington Building, 900 South Limestone Street, Lexington, KY, 40536-0200, USA
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Therapeutic Advances in the Perioperative Period for Older Adults. Am J Ther 2018. [DOI: 10.1097/mjt.0000000000000668] [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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Association of Postoperative Transfusions With Adverse Outcomes After Noncardiac Surgery. Ann Surg 2017; 266:e69-e70. [PMID: 29136983 DOI: 10.1097/sla.0000000000001518] [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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Suzumura EA, Ribeiro RA, Kawano-Dourado L, de Barros E Silva PG, Oliveira C, Figueiró MF, Cavalcanti AB, Lopes RD, Berwanger O. Effects of perioperative statin use on cardiovascular complications in patients submitted to non-cardiac surgery: protocol for a systematic review, meta-analysis, and trial sequential analysis. Syst Rev 2017; 6:116. [PMID: 28629445 PMCID: PMC5477118 DOI: 10.1186/s13643-017-0500-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Preliminary evidence suggests statins may reduce major perioperative vascular events. However, evidence is limited to observational studies, underpowered trials, and non-comprehensive systematic reviews. This review aims to assess the effects of perioperative statin use on cardiovascular complications in patients submitted to non-cardiac surgery. METHODS We will search MEDLINE/PubMed, EMBASE, LILACS, CENTRAL, Web of Science, and CINAHL for randomized controlled trials assessing the effects of perioperative statin use in adults undergoing non-cardiac surgery and reporting cardiovascular complications. For patients already using statins for hyperlipidemia, a preoperative loading dose of statin is required in the experimental group. We will place no language or publication restriction on our search. Teams of two reviewers will independently assess eligibility and risk of bias, and will extract data from the included trials. Our primary outcome is a combination of cardiovascular mortality or non-fatal myocardial infarction. We will also assess the following outcomes: individual components of the primary outcome, all-cause mortality, total myocardial infarction, elevated troponin in the first seven postoperative days, total stroke, total venous thromboembolism, postoperative atrial fibrillation, elevation of creatine phosphokinase or liver enzymes, and rates of myalgia or rhabdomyolysis. We will conduct meta-analyses using random-effects model and will use trial sequential analysis to establish monitoring boundaries to limit global type I error due to repetitive testing for our primary outcome. We will rate the quality of evidence using the GRADE system. DISCUSSION The results of this systematic review may help to inform clinical practice and also the design of future large-scale randomized trials. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016035987.
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Affiliation(s)
- Erica Aranha Suzumura
- Research Institute, Hospital do Coração (HCor), Rua Abílio Soares 250, 12° andar, CEP: 04005-000, São Paulo, SP, Brazil.
| | - Rodrigo Antonini Ribeiro
- Graduate Program in Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,National Institute of Science and Technology for Health Technology Assessment, CNPq, Brazil.,School of Medicine, Faculdade Meridional - IMED, Passo Fundo, Brazil
| | - Leticia Kawano-Dourado
- Research Institute, Hospital do Coração (HCor), Rua Abílio Soares 250, 12° andar, CEP: 04005-000, São Paulo, SP, Brazil.,Pulmonary Division - Heart Institute (InCor) University of Sao Paulo Medical School, São Paulo, Brazil
| | - Pedro Gabriel de Barros E Silva
- Research Institute, Hospital do Coração (HCor), Rua Abílio Soares 250, 12° andar, CEP: 04005-000, São Paulo, SP, Brazil.,Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | - Claudia Oliveira
- Research Institute, Hospital do Coração (HCor), Rua Abílio Soares 250, 12° andar, CEP: 04005-000, São Paulo, SP, Brazil
| | - Mabel Fernandes Figueiró
- Research Institute, Hospital do Coração (HCor), Rua Abílio Soares 250, 12° andar, CEP: 04005-000, São Paulo, SP, Brazil
| | - Alexandre Biasi Cavalcanti
- Research Institute, Hospital do Coração (HCor), Rua Abílio Soares 250, 12° andar, CEP: 04005-000, São Paulo, SP, Brazil
| | - Renato D Lopes
- Research Institute, Hospital do Coração (HCor), Rua Abílio Soares 250, 12° andar, CEP: 04005-000, São Paulo, SP, Brazil.,Duke Clinical Research Institute (DCRI), Durham, NC, USA.,Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | - Otavio Berwanger
- Research Institute, Hospital do Coração (HCor), Rua Abílio Soares 250, 12° andar, CEP: 04005-000, São Paulo, SP, Brazil
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Hong JH, Sohn SI, Kwak J, Yoo J, Chang HW, Kwon OK, Jung C, Chung I, Bae HJ, Lee JS, Han MK. Dose-Dependent Effect of Statin Pretreatment on Preventing the Periprocedural Complications of Carotid Artery Stenting. Stroke 2017. [PMID: 28626049 DOI: 10.1161/strokeaha.117.016680] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE We investigated whether statin pretreatment can dose dependently reduce periprocedural complications in patients undergoing carotid artery stenting because of symptomatic carotid artery stenosis. METHODS We enrolled a consecutive series of 397 symptomatic carotid artery stenosis (≥50% stenosis on conventional angiography) treated with carotid artery stenting at 2 tertiary university hospitals over a decade. Definition of periprocedural complications included any stroke, myocardial infarction, and death within 1 month after or during the procedure. Statin pretreatment was divided into 3 categories according to the atorvastatin equivalent dose: none (n=158; 39.8%), standard dose (<40 mg of atorvastatin, n=155; 39.0%), and high dose (≥40 mg; n=84; 21.2%). A multivariable logistic regression analysis with the generalized estimating equation method was used to investigate independent factors in periprocedural complications. RESULTS The patients' mean age was 68.7 years (81.6% men). The periprocedural complication rates across the 3 categories of statin use were 12.0%, 4.5%, and 1.2%. After adjustment, a change in the atorvastatin dose category was associated with reduction in the odds of periprocedural complications for each change in dose category (standard-dose statin: odds ratio, 0.24; 95% confidence interval, 0.07-0.81; high-dose statin: odds ratio, 0.11; 95% confidence interval, 0.01-0.96; P for trend=0.01). Administration of antiplatelet drugs was also an independent factor in periprocedural complications (OR, 0.18; 95% CI, 0.05-0.69). CONCLUSIONS This study shows that statin pretreatment may reduce the incidence of periprocedural complications dose dependently in patients with symptomatic carotid artery stenting.
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Affiliation(s)
- Jeong-Ho Hong
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Sung-Il Sohn
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Jaehyuk Kwak
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Joonsang Yoo
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Hyuk Won Chang
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - O-Ki Kwon
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Cheolkyu Jung
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Inyoung Chung
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Hee-Joon Bae
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Ji Sung Lee
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.)
| | - Moon-Ku Han
- From the Department of Neurology (J.-H.H., S.-I.S., J.K., J.Y.); Department of Radiology (H.W.C.), Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea; Department of Neurology (I.C., H.-J.B., M.-K.H.), Department of Neurosurgery (O.-K.K.), and Department of Radiology (C.J.), Seoul National University Bundang Hospital, Seongnam, Korea; and Clinical Trial Center, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Korea (J.S.L.).
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Meltzer AJ, Sedrakyan A, Connolly PH, Ellozy S, Schneider DB. Risk Factors for Suboptimal Utilization of Statins and Antiplatelet Therapy in Patients Undergoing Revascularization for Symptomatic Peripheral Arterial Disease. Ann Vasc Surg 2017; 46:234-240. [PMID: 28602895 DOI: 10.1016/j.avsg.2017.05.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 02/13/2017] [Accepted: 05/17/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND The objective of this study was to identify risk factors for suboptimal medical therapy (defined as reported antiplatelet and statin use) among patients undergoing lower extremity bypass (LEB) and peripheral vascular interventions (PVIs) for symptomatic peripheral arterial disease (PAD). METHODS The Vascular Study Group of Greater New York (VSGGNY) database was used to identify all patients undergoing PVI or LEB for PAD (2011-2013). Bivariate analyses were performed to identify characteristics of patients who were not prescribed statins and/or antiplatelet agents before revascularization. Multivariate relative risk regression models were developed to identify patients at risk for suboptimal therapy, with regards to antiplatelet and statin therapy. RESULTS About 1,030 patients underwent endovascular therapy (n = 822; 80%) or surgical bypass (n = 208; 20%) for symptomatic PAD (57.2% claudication; 15% rest pain and 27.8% tissue loss). Overall, preoperative statin use was observed in 59%. Preoperative antiplatelet therapy was observed in 79% of patients. Bivariate analysis revealed comparatively reduced statin use among patients without other cardiovascular risk factors including hypertension (63% vs. 39.3%; P < 0.0001) and coronary artery disease (CAD) with or without prior cardiac revascularization (coronary artery bypass grafting [CABG]/percutaneous coronary intervention [PCI]; 75.2% vs. 47.4%; P < 0.0001). Multivariate relative risk regression confirmed higher rates of statin use among patients with other cardiovascular risk factors including hypertension (1.14 [1.02-1.27]; P = 0.02) and CAD with prior CABG/PCI (1.22 [1.13-1.31]; P < 0.0001). Reduced statin use was observed in patients over 80 years old. (0.92 [0.84-0.1.0]; P = 0.059). By multivariate regression, antiplatelet therapy use was associated with CAD and/or prior CABG/PCI (1.11 [1.04-1.17]; P = 0.0015) and prior peripheral revascularization (1.07 [1.01-1.13]; P = 0.03). CONCLUSIONS Patients with symptomatic PAD, but without an antecedent cardiovascular history, are less likely to be optimally managed with statins and antiplatelet therapy preoperatively. Given the established role of these medications in the optimal medical management of patients with PAD, this presents an opportunity for improvement in the overall vascular care of patients undergoing intervention for symptomatic PAD at VSGGNY centers.
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Affiliation(s)
- Andrew J Meltzer
- Vascular and Endovascular Surgery, Weill Cornell Medical College, New York City, NY.
| | - Art Sedrakyan
- Vascular and Endovascular Surgery, Weill Cornell Medical College, New York City, NY
| | - Peter H Connolly
- Vascular and Endovascular Surgery, Weill Cornell Medical College, New York City, NY
| | - Sharif Ellozy
- Vascular and Endovascular Surgery, Weill Cornell Medical College, New York City, NY
| | - Darren B Schneider
- Vascular and Endovascular Surgery, Weill Cornell Medical College, New York City, NY
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- Vascular and Endovascular Surgery, Weill Cornell Medical College, New York City, NY
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Galyfos G, Sianou A, Filis K. Pleiotropic effects of statins in the perioperative setting. Ann Card Anaesth 2017; 20:S43-S48. [PMID: 28074822 PMCID: PMC5299828 DOI: 10.4103/0971-9784.197796] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Statins belong to a specific group of drugs that have been described for their ability to control hyperlipidemia as well as for other pleiotropic effects such as improving vascular endothelial function, inhibition of oxidative stress pathways, and anti-inflammatory actions. Accumulating clinical evidence strongly suggests that statins also have a beneficial effect on perioperative morbidity and mortality. Therefore, this review aims to present all recent and pooled data on statin treatment in the perioperative setting as well as to highlight considerations regarding their indications and therapeutic application.
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Affiliation(s)
- George Galyfos
- Department of Propaedeutic Surgery, Division of Vascular Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Argyri Sianou
- Department of Microbiology, University of Athens Medical School, Areteion Hospital, Athens, Greece
| | - Konstantinos Filis
- Department of Propaedeutic Surgery, Division of Vascular Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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Management of Modifiable Vascular Risk Factors Improves Late Survival following Abdominal Aortic Aneurysm Repair: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2017; 39:301-311. [DOI: 10.1016/j.avsg.2016.07.066] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/21/2016] [Accepted: 07/27/2016] [Indexed: 11/21/2022]
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Berwanger O, de Barros E Silva PGM, Barbosa RR, Precoma DB, Figueiredo EL, Hajjar LA, Kruel CDP, Alboim C, Almeida AP, Dracoulakis MDA, Filho HV, Carmona MJC, Maia LN, de Oliveira Filho JB, Saraiva JFK, Soares RM, Damiani L, Paisani D, Kodama AA, Gonzales B, Ikeoka DT, Devereaux PJ, Lopes RD. Atorvastatin for high-risk statin-naïve patients undergoing noncardiac surgery: The Lowering the Risk of Operative Complications Using Atorvastatin Loading Dose (LOAD) randomized trial. Am Heart J 2017; 184:88-96. [PMID: 27892891 DOI: 10.1016/j.ahj.2016.11.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 11/04/2016] [Indexed: 02/06/2023]
Abstract
Preliminary evidence suggests that statins may prevent major perioperative vascular complications. METHODS We randomized 648 statin-naïve patients who were scheduled for noncardiac surgery and were at risk for a major vascular complication. Patients were randomized to a loading dose of atorvastatin or placebo (80 mg anytime within 18hours before surgery), followed by a maintenance dose of 40 mg (or placebo), started at least 12hours after the surgery, and then 40 mg/d (or placebo) for 7days. The primary outcome was a composite of all-cause mortality, nonfatal myocardial injury after noncardiac surgery, and stroke at 30days. RESULTS The primary outcome was observed in 54 (16.6%) of 326 patients in the atorvastatin group and 59 (18.7%) of 316 patients in the placebo group (hazard ratio [HR] 0.87, 95% CI 0.60-1.26, P=.46). No significant effect was observed on the 30-day secondary outcomes of all-cause mortality (4.3% vs 4.1%, respectively; HR 1.14, 95% CI 0.53-2.47, P=.74), nonfatal myocardial infarction (3.4% vs 4.4%, respectively; HR 0.76, 95% CI 0.35-1.68, P=.50), myocardial injury after noncardiac surgery (13.2% vs 16.5%; HR 0.79, 95% CI 0.53-1.19, P=.26), and stroke (0.9% vs 0%, P=.25). CONCLUSION In contrast to the prior observational and trial data, the LOAD trial has neutral results and did not demonstrate a reduction in major cardiovascular complications after a short-term perioperative course of statin in statin-naïve patients undergoing noncardiac surgery. We demonstrated, however, that a large multicenter blinded perioperative statin trial for high-risk statin-naïve patients is feasible and should be done to definitely establish the efficacy and safety of statin in this patient population.
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Affiliation(s)
- Otavio Berwanger
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil.
| | - Pedro G M de Barros E Silva
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil; Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil
| | | | | | | | - Ludhmila Abrahão Hajjar
- Instituto do Câncer do estado de São Paulo (ICESP), Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil
| | | | - Carolina Alboim
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Hugo Vargas Filho
- Hospital São Vicente de Paulo, Passo Fundo, Rio Grande do Sul, Brazil
| | - Maria José Carvalho Carmona
- Divisão de Anestesia Instituto Central-Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | | | - Rafael M Soares
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | - Lucas Damiani
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | - Denise Paisani
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | | | - Beatriz Gonzales
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | - Dimas T Ikeoka
- Research Institute-Hospital do Coracao (HCOR), São Paulo, Brazil
| | | | - Renato D Lopes
- Brazilian Clinical Research Institute (BCRI), São Paulo, Brazil; Duke Clinical Research Institute, Durham, NC
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Ballotta E, Toniato A, Farina F, Baracchini C. Effects of preoperative statin use on perioperative outcomes of carotid endarterectomy. Brain Behav 2017; 7:e00597. [PMID: 28127515 PMCID: PMC5256180 DOI: 10.1002/brb3.597] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/10/2016] [Accepted: 09/24/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Several studies have shown the beneficial role of statins in reducing the risk of major perioperative complications and death associated with noncardiac vascular surgery, but few have focused on their effects in the event of carotid endarterectomy (CEA). This study analyzes the effects of preoperative statin use on perioperative outcomes in patients undergoing CEA. MATERIALS AND METHODS Data from all consecutive patients who underwent primary CEA for symptomatic and asymptomatic carotid disease between 2002 and 2014 at a single institution were prospectively stored in a vascular surgery registry, recording risk factors, medication, and indication for surgery. Endpoints of the study were perioperative (30-day) stroke and death. RESULTS Overall, 784 patients were on statins (825 CEAs, Group I), while 494 were not (545 CEAs, Group II). There were two perioperative strokes in Group I (0.24%) and four in Group II (0.73%; p = .22), and no deaths. The only nonfatal cardiac complication occurred in Group II (0.18%, p = .39). A neurologist assessed patients at 1, 6, and 12 months after CEA, and every 2 years thereafter. Follow-up (range: 0.1-13 years; mean, 6.3 ± 3.7 years) was obtained for 1,239 patients (1,326 CEAs). Because 165 patients (166 CEAs) crossed over from Group II to Group I during the follow-up time, long-term data were stratified by postoperative statin treatment rather than by preoperative statin use. The 5- and 10-year restenosis/occlusion and survival rates did not differ significantly between the two groups. CONCLUSIONS Taking statins prior to CEA did not seem to affect the risk of major perioperative ischemic events and death, most likely due to the extremely low overall incidence of perioperative complications.
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Affiliation(s)
- Enzo Ballotta
- The Vascular Surgery GroupDepartment of SurgicalOncological and Gastroenterological SciencesSchool of MedicineUniversity of PaduaPadovaItaly
| | - Antonio Toniato
- The Vascular Surgery GroupDepartment of SurgicalOncological and Gastroenterological SciencesSchool of MedicineUniversity of PaduaPadovaItaly
| | - Filippo Farina
- Stroke Unit and Neurosonology LaboratoryDepartment of NeurosciencesSchool of MedicineUniversity of PaduaPadovaItaly
| | - Claudio Baracchini
- Stroke Unit and Neurosonology LaboratoryDepartment of NeurosciencesSchool of MedicineUniversity of PaduaPadovaItaly
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Chaturvedi S, Chimowitz M, Brown RD, Lal BK, Meschia JF. The urgent need for contemporary clinical trials in patients with asymptomatic carotid stenosis. Neurology 2016; 87:2271-2278. [PMID: 27683853 DOI: 10.1212/wnl.0000000000003267] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/10/2016] [Indexed: 11/15/2022] Open
Abstract
Asymptomatic extracranial internal carotid artery atherosclerotic stenosis increases with age and is more common in men. Studies performed more than 2 decades ago showed that carotid endarterectomy reduced the rate of stroke in carefully selected patients with asymptomatic carotid stenosis compared with medical therapy in the long term. Those trials were completed more than 20 years ago and with advances in the treatment of atherosclerotic disease, the question has been raised to as to whether endarterectomy is still of value for patients with asymptomatic narrowing. Perioperative risk of carotid revascularization procedures has also declined. Due to improvements in both medical and surgical treatments for carotid artery stenosis, it is timely to reevaluate the efficacy of carotid intervention relative to medical treatment for patients with asymptomatic stenosis.
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Affiliation(s)
- Seemant Chaturvedi
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL.
| | - Marc Chimowitz
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - Robert D Brown
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - Brajesh K Lal
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
| | - James F Meschia
- From the University of Miami Miller School of Medicine (S.C.), FL; Medical University of South Carolina (M.C.), Charleston; Mayo Clinic (R.D.B.), Rochester, MN; University of Maryland School of Medicine (B.K.L.), Baltimore; and Mayo Clinic (J.F.M.), Jacksonville, FL
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Affiliation(s)
- Nathaniel R Smilowitz
- From Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY (N.R.S., J.S.B.); Division of Hematology, Department of Medicine, New York University School of Medicine, New York, NY (J.S.B.); and Division of Vascular Surgery, Department of Surgery, New York University School of Medicine, New York, NY (J.S.B.)
| | - Jeffrey S Berger
- From Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY (N.R.S., J.S.B.); Division of Hematology, Department of Medicine, New York University School of Medicine, New York, NY (J.S.B.); and Division of Vascular Surgery, Department of Surgery, New York University School of Medicine, New York, NY (J.S.B.).
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Sundsted KK, Mohabbat AB, Regan DW, Salonen BR, Daniels PR, Mauck KF. Update in perioperative medicine: practice-changing evidence published in 2015. Hosp Pract (1995) 2016; 44:157-63. [PMID: 27400757 DOI: 10.1080/21548331.2016.1210473] [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: 10/21/2022]
Abstract
Evidence in perioperative medicine is published in a wide variety of journals, given the multidisciplinary nature of its practice which spans medicine and its subspecialties, as well as surgery and anesthesiology. It can be difficult to identify new and important evidence, as perioperative practice continues to evolve in multiple areas such as medication management, anticoagulation and cardiac risk stratification, among others. New, high-quality evidence is published each year, and must be placed into the context of not only existing literature, but also practical real-world patient care. We sought to systematically identify, critically evaluate and concisely summarize the practice implications of 10 articles published in 2015 for the practicing perioperative clinician.
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Affiliation(s)
- Karna K Sundsted
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Arya B Mohabbat
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Dennis W Regan
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Bradley R Salonen
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Paul R Daniels
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
| | - Karen F Mauck
- a Division of General Internal Medicine, Department of Medicine , Mayo Clinic and Mayo Clinic College of Medicine , Rochester , MN , USA
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Priebe HJ. Pharmacological modification of the perioperative stress response in noncardiac surgery. Best Pract Res Clin Anaesthesiol 2016; 30:171-89. [DOI: 10.1016/j.bpa.2016.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 03/21/2016] [Accepted: 03/31/2016] [Indexed: 11/26/2022]
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Bartline PB, Brooke BS. Using implementation science to help integrate preoperative evidence-based measures into practice for vascular surgery patients. Semin Vasc Surg 2015; 28:68-79. [PMID: 26655049 DOI: 10.1053/j.semvascsurg.2015.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The preoperative workup is a necessary and crucial evaluation for patients undergoing major vascular surgery. It is important to assess for likelihood of perioperative adverse events and then implement evidence-based measures to reduce identified medical comorbidities and improve the quality of patient care and outcomes after surgery. Although there are numerous opportunities to implement evidence-based processes during the preoperative period, there are many barriers that can prevent vascular surgeons from achieving these goals. This review will discuss how an implementation science-based approach can be used by members of the vascular surgery team to identify appropriate preoperative evidence-based interventions for diverse practice settings and to overcome barriers and allow integration of these interventions as part of the routine preoperative workup.
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Affiliation(s)
- Peter B Bartline
- Division of Vascular Surgery, University of Utah School of Medicine, 30 N. 1900 E., Suite #3C344, Salt Lake City, UT 84132
| | - Benjamin S Brooke
- Division of Vascular Surgery, University of Utah School of Medicine, 30 N. 1900 E., Suite #3C344, Salt Lake City, UT 84132.
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De Martino RR, Beck AW, Hoel AW, Hallett JW, Arya S, Upchurch GR, Cronenwett JL, Goodney PP. Preoperative antiplatelet and statin treatment was not associated with reduced myocardial infarction after high-risk vascular operations in the Vascular Quality Initiative. J Vasc Surg 2015; 63:182-9.e2. [PMID: 26409843 DOI: 10.1016/j.jvs.2015.08.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 08/05/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Medical management with antiplatelet (AP) and statin therapy is recommended for nearly all patients undergoing vascular surgery to reduce cardiovascular events. We assessed the association between preoperative use of AP and statin medications and postoperative in-hospital myocardial infarction (MI) in patients undergoing high-risk open surgery. METHODS We studied patients who underwent elective suprainguinal (n = 3039) and infrainguinal (n = 8323) bypass and open infrarenal abdominal aortic aneurysm repair (n = 3007) in the Vascular Quality Initiative (VQI, 2005-2014). We assessed the association between AP or statin use and in-hospital postoperative MI and MI/death. Multivariable logistic analyses were performed to identify the patient, procedure, and preoperative medication factors associated with postoperative MI and MI/death across procedures and patient cardiac risk strata. Secondary end points included bleeding, transfusion, and thrombotic complications. RESULTS Most patients were taking both AP and statin preoperatively (56% both agents vs 19% AP only, 13% statin only, and 12% neither agent). Use of both agents was more common for patients in the highest cardiac risk stratum (low, 54%; intermediate, 59%; high, 61%; P < .01). Increased cardiac risk was associated with higher MI rates (1.8% vs 3.8% vs 6.5% for low, intermediate, and high risk; P < .01). By univariate analysis, MI rate was paradoxically higher for patients taking both agents (3.7%, vs statin only 2.8%, AP only 2.6%, or neither AP nor statin 2.4%; P = .003). After multivariable adjustment, rates of MI in patients taking preoperative AP only (odds ratio [OR], 0.9; 95% confidence interval [CI], 0.7-1.2) and statin only (OR, 0.8; 95% CI, 0.6-1.2) were not different from those in patients taking either or neither medication (neither agent compared with taking both agents: OR, 1.0; 95% CI, 0.7-1.4; P > .05 for all). Similarly, rates of MI/death were not associated with medication status after multivariable adjustment. Estimated blood loss >1 liter (OR, 2.4; 95% CI, 1.6-3.7; P < .01) and transfusions of 1 or 2 units (OR, 2.5; 95% CI, 2.0-3.3; P < .01) and ≥3 units (OR, 4.0; 95% CI, 3.1-5.3; P < .01) were highly associated with MI, with similar findings related to composite MI/death in multivariable analysis. Rates of blood loss were slightly higher with AP use for all procedures; however, increased transfusions occurred only for infrainguinal bypass with AP use. Rates of reoperation for bleeding, graft thrombosis, or graft revision did not differ by preoperative AP use. CONCLUSIONS Preoperative AP and statin medications as used in VQI were not associated with the rate of in-hospital MI/death after major open vascular operations. Rather, predicted cardiac risk and operative blood loss were significantly associated with in-hospital MI or MI/death. AP and statin medications appear to be more useful in reducing late mortality than early postoperative MI/death in VQI. However, they were not harmful, so their long-term benefit argues for continued use.
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Affiliation(s)
| | - Adam W Beck
- Division of Vascular Surgery & Endovascular Therapy, University of Florida College of Medicine, Gainesville, Fla
| | - Andrew W Hoel
- Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - John W Hallett
- Roper Vascular Care, Roper St. Francis Heart & Vascular Center, Charleston, SC
| | - Shipra Arya
- Division of Vascular Surgery and Endovascular Therapy, Emory University, Atlanta, Ga
| | - Gilbert R Upchurch
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, Va
| | - Jack L Cronenwett
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Philip P Goodney
- Division of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Vlisides P, Mashour GA. Perioperative stroke. Can J Anaesth 2015; 63:193-204. [PMID: 26391795 DOI: 10.1007/s12630-015-0494-9] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 07/02/2015] [Accepted: 09/11/2015] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Perioperative stroke is associated with significant morbidity and mortality, with an incidence that may be underappreciated. In this review, we examine the significance, pathophysiology, risk factors, and evidence-based recommendations for the prevention and management of perioperative stroke. SOURCE This is a narrative review based on literature from the PubMed database regarding perioperative stroke across a broad surgical population. The Society for Neuroscience in Anesthesiology and Critical Care recently published evidence-based recommendations for perioperative management of patients at high risk for stroke; these recommendations were analyzed and incorporated into this review. PRINCIPAL FINDINGS The incidence of overt perioperative stroke is highest in patients presenting for cardiac and major vascular surgery, although preliminary data suggest that the incidence of covert stroke may be as high as 10% in non-cardiac surgery patients. The pathophysiology of perioperative stroke involves different pathways. Thrombotic stroke can result from increased inflammation and hypercoagulability; cardioembolic stroke can result from disease states such as atrial fibrillation, and tissue hypoxia from anemia can result from the combination of anemia and beta-blockade. Across large-scale database studies, common risk factors for perioperative stroke include advanced age, history of cerebrovascular disease, ischemic heart disease, congestive heart failure, atrial fibrillation, and renal disease. Recommendations for prevention and management of perioperative stroke are evolving, though further work is needed to clarify the role of proposed modifiable risk factors such as perioperative anticoagulation, antiplatelet therapy, appropriate transfusion thresholds, and perioperative beta-blockade. CONCLUSIONS Perioperative stroke carries a significant clinical burden. The incidence of perioperative stroke may be higher than previously recognized, and there are diverse pathophysiologic mechanisms. There are many opportunities for further investigation of the pathophysiology, prevention, and management of perioperative stroke.
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Affiliation(s)
- Phillip Vlisides
- Department of Anesthesiology, University of Michigan Health System, University Hospital 1H247, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109, USA
| | - George A Mashour
- Department of Anesthesiology, University of Michigan Health System, University Hospital 1H247, 1500 East Medical Center Drive, SPC 5048, Ann Arbor, MI, 48109, USA.
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Berwanger O, Le Manach Y, Suzumura EA, Biccard B, Srinathan SK, Szczeklik W, Santo JAE, Santucci E, Cavalcanti AB, Archbold RA, Devereaux PJ. Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. Eur Heart J 2015; 37:177-85. [PMID: 26330424 DOI: 10.1093/eurheartj/ehv456] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 08/17/2015] [Indexed: 12/17/2022] Open
Abstract
AIMS The aim of this study was to assess the effects of pre-operative statin therapy on cardiovascular events in the first 30-days after non-cardiac surgery. METHODS AND RESULTS We conducted an international, prospective, cohort study of patients who were ≥45 years having in-patient non-cardiac surgery. We estimated the probability of receiving statins pre-operatively using a multivariable logistic model and conducted a propensity score analysis to correct for confounding. A total of 15 478 patients were recruited at 12 centres in eight countries from August 2007 to January 2011. The matched population consisted of 2845 patients (18.4%) treated with a statin and 4492 (29.0%) controls. The pre-operative use of statins was associated with lower risk of the primary outcome, a composite of all-cause mortality, myocardial injury after non-cardiac surgery (MINS), or stroke at 30 days [relative risk (RR), 0.83; 95% confidence interval (CI), 0.73-0.95; P = 0.007]. Statins were also associated with a significant lower risk of all-cause mortality (RR, 0.58; 95% CI, 0.40-0.83; P = 0.003), cardiovascular mortality (RR, 0.42; 95% CI, 0.23-0.76; P = 0.004), and MINS (RR, 0.86; 95% CI, 0.73-0.98; P = 0.02). There were no statistically significant differences in the risk of myocardial infarction or stroke. CONCLUSION Among patients undergoing non-cardiac surgery, pre-operative statin therapy was independently associated with a lower risk of cardiovascular outcomes at 30 days. These results require confirmation in a large randomized trial. CLINICAL TRIAL REGISTRATION Clinical Trials.gov NCT00512109.
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Affiliation(s)
- Otavio Berwanger
- Research Institute - Heart Hospital (Hospital do Coração - HCor), Rua Abílio Soares 250, 12 Andar, São Paulo, SP 04005-000, Brazil
| | - Yannick Le Manach
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Erica Aranha Suzumura
- Research Institute - Heart Hospital (Hospital do Coração - HCor), Rua Abílio Soares 250, 12 Andar, São Paulo, SP 04005-000, Brazil
| | - Bruce Biccard
- Perioperative Research Group, Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | | | - Jose A Espirito Santo
- Research Institute - Heart Hospital (Hospital do Coração - HCor), Rua Abílio Soares 250, 12 Andar, São Paulo, SP 04005-000, Brazil
| | - Eliana Santucci
- Research Institute - Heart Hospital (Hospital do Coração - HCor), Rua Abílio Soares 250, 12 Andar, São Paulo, SP 04005-000, Brazil
| | - Alexandre B Cavalcanti
- Research Institute - Heart Hospital (Hospital do Coração - HCor), Rua Abílio Soares 250, 12 Andar, São Paulo, SP 04005-000, Brazil
| | | | - P J Devereaux
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
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