[Preoperative evaluation of adult patients before elective, non-cardiothoracic surgery : A joint recommendation of the German Society for Anesthesiology and Intensive Care Medicine, the German Society for Surgery and the German Society for Internal Medicine]

The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.

The impact of statin use before intensive care unit admission on patients with acute kidney injury after cardiac surgery

Background: Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common and serious complication after cardiac surgery. The influence of statin use before surgery on the renal outcome of patients undergoing cardiac surgery is controversial. The purpose of this study was to evaluate the effect of statins on postoperative renal outcomes in patients undergoing cardiac surgery. Methods: We included CSA-AKI patients in the Medical Information Mart for Intensive Care (MIMIC)-IV database and were divided into statin group and non-statin group according to whether they used statins before entering intensive care units (ICU). The main outcomes were hospitalization and 30-day mortality, and the secondary outcomes were 60-day mortality and 90-day mortality. We used propensity score matching (PSM) to adjust for confounding factors. The 95% confidence interval (CI) and risk ratio (RO) were calculated by the COX proportional regression model. At the same time, stratified analysis was used to explore whether the relationship between the statins use before intensive care units and mortality was different in each subgroup and whether the relationship between different doses of Atorvastatin and mortality was different. Result: We identified 675 pre-ICU statin users and 2095 non-statin users. In the COX proportional regression model, pre-ICU statin use was associated with decreased in-hospital (HR = 0.407, 95%confidence interval 0.278-0.595, p < 0.001) and 30-day mortality (HR = 0.407, 95%CI 0.279-0.595, p < 0.001). The survival rate of patients who took statins before entering ICU was significantly higher than that of those who did not use statins at 30 days, 60 days and 90 days. There is a significant interaction between patients with aged>65 years (HR = 0.373, 95%CI 0.240-0.581, p < 0.001), Acute kidney injury grade I (HR = 0.244, 95%CI 0.118-0.428, p < 0.001), and without post-myocardial infarction syndrome (HR = 0.344, 95%CI 0.218-0.542, p < 0.001). The mortality in hospital and 60 days of CSA-AKI patients treated with ≥80 mg Atorvastatin before operation was significantly reduced (p < 0.05). Conclusion: The pre-ICU statin use was significantly associated with decreased risk in hospital and 30-day mortality. The preoperative use of ≥80 mg Atorvastatin may improve the prognosis of CSA-AKI.

Impact of the Main Cardiovascular Risk Factors on Plasma Extracellular Vesicles and Their Influence on the Heart's Vulnerability to Ischemia-Reperfusion Injury

The majority of cardiovascular deaths are associated with acute coronary syndrome, especially ST-elevation myocardial infarction. Therapeutic reperfusion alone can contribute up to 40 percent of total infarct size following coronary artery occlusion, which is called ischemia-reperfusion injury (IRI). Its size depends on many factors, including the main risk factors of cardiovascular mortality, such as age, sex, systolic blood pressure, smoking, and total cholesterol level as well as obesity, diabetes, and physical effort. Extracellular vesicles (EVs) are membrane-coated particles released by every type of cell, which can carry content that affects the functioning of other tissues. Their role is essential in the communication between healthy and dysfunctional cells. In this article, data on the variability of the content of EVs in patients with the most prevalent cardiovascular risk factors is presented, and their influence on IRI is discussed.

The cardioprotective actions of statins in targeting mitochondrial dysfunction associated with myocardial ischaemia-reperfusion injury

During cardiac reperfusion after myocardial infarction, the heart is subjected to cascading cycles of ischaemia reperfusion injury (IRI). Patients presenting with this injury succumb to myocardial dysfunction resulting in myocardial cell death, which contributes to morbidity and mortality. New targeted therapies are required if the myocardium is to be protected from this injury and improve patient outcomes. Extensive research into the role of mitochondria during ischaemia and reperfusion has unveiled one of the most important sites contributing towards this injury; specifically, the opening of the mitochondrial permeability transition pore. The opening of this pore occurs during reperfusion and results in mitochondria swelling and dysfunction, promoting apoptotic cell death. Activation of mitochondrial ATP-sensitive potassium channels (mitoK_ATP) channels, uncoupling proteins, and inhibition of glycogen synthase kinase-3β (GSK3β) phosphorylation have been identified to delay mitochondrial permeability transition pore opening and reduce reactive oxygen species formation, thereby decreasing infarct size. Statins have recently been identified to provide a direct cardioprotective effect on these specific mitochondrial components, all of which reduce the severity of myocardial IRI, promoting the ability of statins to be a considerate preconditioning agent. This review will outline what has currently been shown in regard to statins cardioprotective effects on mitochondria during myocardial IRI.

Perioperative pharmacotherapy to prevent cardiac complications in patients undergoing noncardiac surgery

Introduction: Despite advances in surgical and anesthetic techniques, perioperative cardiovascular complications are a major cause of 30-day perioperative mortality. Major cardiovascular complications after noncardiac surgery include myocardial ischemia, congestive heart failure, arrhythmias, and cardiac arrest. Along with surgical risk assessment, perioperative medical optimization can reduce the rates and clinical impact of these complications.Areas Covered: In this review, the authors discuss the pharmacological basis, existing evidence, and professional society recommendations for drug management in preventing cardiovascular complications in patients undergoing noncardiac surgery.Expert opinion: Perioperative management of cardiovascular disease is an increasingly important and growing area of clinical practice. Societal guidelines regarding the use of most routine cardiovascular medications are based on a number of large clinical studies and provide a basic foundation to guide management. However, the heterogeneous nature of patients, as well as surgeries, makes it practically impossible to devise a 'one size fits all' recommendation in this setting. Thus, the importance of a more individualized approach to perioperative risk stratification and management is being increasingly recognized. The underlying comorbidities and cardiac profile as well as the risk of cardiac complications associated with the planned surgery must be factored in to understand the nuance of the management strategies.

Actual Issues of the Cardiac Complications Risk Assessment and Correction in Non-Cardiac Surgery

Worldwide, more than 200 million non-cardiac surgeries are performed annually, and this number is constantly increasing; cardiac complications are the leading cause of death in such surgeries. So, in a multicenter study conducted in 27 countries, cardiovascular complications were present in 68% of cases of death in the postoperative period. Registers of recent years have shown that the number of such complications remains high, for example, with a dynamic assessment of troponins, perioperative myocardial damage was detected in 13-18% of cases. This review provides a critical analysis of the step-by-step algorithm for assessing cardiac risk of non-cardiac operations considering the emergence of new publications on this topic. The review discusses new data on risk assessment scales, functional state assessment, the use of non-invasive tests, biomarkers, the role of preventive myocardial revascularization in the preoperative period, and drug therapy. The issues of non-cardiac operations after percutaneous coronary intervention, perioperative myocardial damage are considered separately. The review emphasizes the difficulties in obtaining evidence, conducting randomized clinical trials in this section of medicine, which do not allow obtaining unambiguous conclusions in most cases and lead to inconsistencies and ambiguities in the recommendations of various expert groups. This review will help practitioners navigate this issue and help to use the optimal diagnostic and treatment strategy before performing non-cardiac surgery.

Non-cardiac surgery in patients with coronary artery disease: risk evaluation and periprocedural management

Perioperative cardiovascular complications are important causes of morbidity and mortality associated with non-cardiac surgery, particularly in patients with coronary artery disease (CAD). Although preoperative cardiac risk assessment can facilitate the identification of vulnerable patients and implementation of adequate preventive measures, excessive evaluation might lead to undue resource utilization and surgical delay. Owing to conflicting data, there remains some uncertainty regarding the most beneficial perioperative strategy for patients with CAD. Antithrombotic agents are the cornerstone of secondary prevention of ischaemic events but substantially increase the risk of bleeding. Given that 5-25% of patients undergoing coronary stent implantation require non-cardiac surgery within 2 years, surgery is the most common reason for premature cessation of dual antiplatelet therapy. Perioperative management of antiplatelet therapy, which necessitates concomitant evaluation of the individual thrombotic and bleeding risks related to both clinical and procedural factors, poses a recurring dilemma in clinical practice. Current guidelines do not provide detailed recommendations on this topic, and the optimal approach in these patients is yet to be determined. This Review summarizes the current data guiding preoperative risk stratification as well as periprocedural management of patients with CAD undergoing non-cardiac surgery, including those treated with stents.

Postoperative statin treatment may be associated with improved mortality in patients with myocardial injury after noncardiac surgery

Myocardial injury after noncardiac surgery (MINS) is recently accepted as a strong predictor of mortality, regardless of symptoms. However, anticoagulation is the only established treatment. This study aimed to evaluate the association between statin treatment and mortality after MINS. From January 2010 to June 2019, a total of 5,267 adult patients who were discharged after the occurrence of MINS were enrolled. The patients were divided into two groups according to statin prescription at discharge. The outcomes were 1-year and overall mortalities. Of the total 5,109 patients, 1,331 (26.1%) patients were in the statin group and 3,778 (73.9%) patients were in the no statin group. The 1-year and overall mortalities were significantly lower in the statin group compared with the no statin group (6.1% vs. 13.3%; hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.41–0.74; p < 0.001 for 1-year mortality and 15.0% vs. 25.0%; HR, 0.62; 95% CI, 0.51–0.76; p < 0.001 for overall mortality). Analyses after inverse probability treatment weighting showed similar results (HR, 0.61; 95% CI, 0.50–0.74; p < 0.001 for 1-year mortality and HR, 0.70; 95% CI, 0.54–0.90; p = 0.006 for overall mortality), and the mortalities did not differ according to the dose of statin. Our results suggest that statin treatment may be associated with improved survival after MINS. A trial is needed to confirm this finding and establish causality.

Adverse Cardiovascular Events Associated With Female Pelvic Reconstructive Surgery

OBJECTIVE

To evaluate national trends in major adverse cardiovascular and cerebrovascular events (MACCE) in female pelvic reconstructive surgery (FPRS).

METHODS

Data from the National Inpatient Sample was used to identify women undergoing FPRS between 2012 and 2016. Demographic, procedural, and comorbidity data were collected. Patients were stratified into those with and without MACCE (defined as all-cause mortality, cardiac arrest, myocardial infarction (MI) and acute ischemic stroke). Descriptive statistics are expressed as medians and interquartile ranges. Pairwise analysis was performed using Wilcoxon rank-sum or Fisher exact test as appropriate. Multivariable logistic regression was used to identify independent risk factors for MACCE.

RESULTS

During the study period, 53,540 patients underwent FPRS. The rate of MACCE was 4.8 per 1000 surgeries; MI, 3.7; acute ischemic stroke, 0.6; cardiac arrest, 0.4; and all-cause mortality, 0.3. Patients experiencing MACCE were more likely to have major preexisting cardiovascular comorbidities, coagulopathy, neurologic disease (ND), and diabetes and were more likely to undergo robotic colpopexy (20.7% vs 9.6%, P < 0.001), vaginal colpopexy (32.0% vs 28.5%, P = 0.04), and to receive a blood transfusion (8.2% vs 2.5%, P < 0.001).On logistic regression, preexisting coagulopathy was the strongest predictor of MACCE (adjusted odds ratio [aOR], 5.53; 95% confidence interval [CI], 2.39-12.78), followed by blood transfusion (aOR, 4.84; 95% CI, 1.89-12.45), congestive heart failure (aOR, 3.61; 95% CI, 1.56-8.37), ND (aOR, 3.14; 95% CI, 1.23-8.06), and electrolyte abnormalities (aOR, 1.99; 95% CI, 1.05-3.99).

CONCLUSION

Major adverse cardiovascular and cerebrovascular events after FPRS is a rare event, with MI being the most common manifestation. Preexisting ND, congestive heart failure, coagulopathy, electrolyte disturbances, and perioperative transfusions are strongly associated with MACCE.

Statins in the perioperative period

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.

Medical therapy for atherosclerotic cardiovascular disease in patients with myocardial injury after non-cardiac surgery

BACKGROUND

Myocardial injury after non-cardiac surgery (MINS) is a common post-operative cardiovascular complication and is associated with short and long-term mortality. The objective of this study was to describe the contemporary management of patients with and without MINS after total joint and spine orthopedic surgery at a large urban health system in the United States.

METHODS

Adults admitted for total joint and major spine surgery from January 2013 through December 2015 with ≥1 cardiac troponin (cTn) measurement during their hospitalization were identified. MINS was defined by a peak cTn above the 99th percentile of the upper reference limit. Demographics, medical comorbidities, and admission and discharge medications were reviewed for all patients.

RESULTS

A total of 2561 patients underwent 2798 orthopedic surgeries, and 236 cases of MINS were identified. Patients with MINS were older (71.9 ± 10.9 vs. 67.0 ± 10.0, p < 0.001) and more likely to have cardiovascular risk factors, including hypertension, chronic kidney disease, prior stroke, coronary artery disease, prior MI, and a history of heart failure. Among patients with MINS, only 112 (47.5%) were discharged on a combination of aspirin and statin. Patients with MINS were more likely to be prescribed a statin (154 [65.3%] vs. 1463 [57.1%], p = 0.018), beta-blocker (147 [62.3%] vs. 1194 [46.6%], p < 0.001), and oral anticoagulation (65 [27.5%] vs. 436 [17.0%], p < 0.001) than patients without MINS.

CONCLUSIONS

The proportion of patients with MINS who were prescribed medical therapy for atherosclerotic cardiovascular disease was low. Additional efforts to determine optimal management of MINS are warranted.

Causes and prevention of postoperative myocardial injury

Over the past few years non-cardiac surgery has been recognised as a serious circulatory stress test which may trigger cardiovascular events such as myocardial infarction, in particular in patients at high risk. Detection of these postoperative cardiovascular events is difficult as clinical symptoms often go unnoticed. To improve detection, guidelines advise to perform routine postoperative assessment of cardiac troponin. Troponin elevation - or postoperative myocardial injury - can be caused by myocardial infarction. However, also non-coronary causes, such as cardiac arrhythmias, sepsis and pulmonary embolism, may play a role in a considerable number of patients with postoperative myocardial injury. It is crucial to acquire more knowledge about the underlying mechanisms of postoperative myocardial injury because effective prevention and treatment options are lacking. Preoperative administration of beta-blockers, aspirin, statins, clonidine, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and preoperative revascularisation have all been investigated as preventive options. Of these, only statins should be considered as the initiation or reload of statins may reduce the risk of postoperative myocardial injury. There is also not enough evidence for intraoperative measures such blood pressure optimisation or intensified medical therapy once patients have developed postoperative myocardial injury. Given the impact, better preoperative identification of patients at risk of postoperative myocardial injury, for example using preoperatively measured biomarkers, would be helpful to improve cardiac optimisation.

Perioperative statin therapy in cardiac and non-cardiac surgery: a systematic review and meta-analysis of randomized controlled trials

Background

The effects of perioperative statin therapy on clinical outcome after cardiac or non-cardiac surgery are controversial. We aimed to assess the association between perioperative statin therapy and postoperative outcome.

Methods

Electronic databases were searched up to May 1, 2018, for randomized controlled trials of perioperative statin therapy versus placebo or no treatment in adult cardiac or non-cardiac surgery. Postoperative outcomes were: myocardial infarction, stroke, acute kidney injury (AKI), and mortality. We calculated risk ratio (RR) or odds ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses. We performed meta-regression and subgroup analyses to assess the possible influence of statin therapy regimen on clinical outcomes and trial sequential analysis to evaluate the risk of random errors and futility.

Results

We included data from 35 RCTs involving 8200 patients. Perioperative statin therapy was associated with lower incidence of postoperative myocardial infarction in non-cardiac surgery (OR = 0.44 [95% CI 0.30–0.64], p < 0.0001), but not in cardiac surgery (OR = 0.93 [95% CI 0.70–1.24], p = 0.61) (p_subgroup = 0.002). Higher incidence of AKI was present in cardiac surgery patients receiving perioperative statins (RR = 1.15 [95% CI 1.00–1.31], p = 0.05), nonetheless not in non-cardiac surgery (RR = 1.52 [95% CI 0.71–3.26], p = 0.28) (p_subgroup = 0.47). No difference in postoperative stroke and mortality was present in either cardiac or non-cardiac surgery. However, low risk of bias trials performed in cardiac surgery showed a higher mortality with statins versus placebo (OR = 3.71 [95% CI 1.03–13.34], p = 0.04). Subgroup and meta-regression analyses failed to find possible relationships between length of statin regimens and clinical outcomes. Trial sequential analysis suggested no firm conclusions on the topic.

Conclusions

Perioperative statins appear to be protective against postoperative myocardial infarction in non-cardiac surgery and associated with higher AKI in cardiac surgery. Possible positive or even negative effects on mortality could not be excluded and merits further investigations. Currently, no randomized evidence supports the systematic administration of statins in surgical patients.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0441-3) contains supplementary material, which is available to authorized users.

Effects of perioperative statins on patient outcomes after noncardiac surgery: a meta-analysis

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.

Postoperative Adverse Cardiovascular Events Associated with Leptin and Adverse Age After Elective Major Non-Cardiac Surgery: An Asian Single-Center Study

BACKGROUND The postoperative adverse cardiovascular events (PACE) after surgery can result in prolonged length of stay and poorer prognosis. The purpose of this Asian single-center study was to investigate the potential predicative role of leptin for PACE in elderly patients undergoing major non-cardiac surgery. MATERIAL AND METHODS The patients in the study were prospectively recruited from a series of elderly patients (≥60 years) undergoing elective major non-cardiac surgery (≥2 hours) in our hospital from June 2013 to June, 2016. The demographic and clinical data and the preoperative serum biomarkers of each participant were recorded in details. Suspected PACE were assessed by the same experienced expert based on clinical, blood, and other accessory tests. The univariate and multiple logistic regression analyses were plotted to evaluate the potential independent predictive factors for PACE. RESULTS A total of 270 elderly patients (145 males and 125 females), undergoing major elective non-cardiac surgery, were finally enrolled in this study. Older age, higher revised cardiac risk index score, higher levels of systolic blood pressure, B-type natriuretic peptide and leptin, the preoperative medication of beta blocker and lipid-lowering agents were positive predictors of PACE by univariate analyses (p<0.05). Our results indicated that preoperative leptin level (OR 1.84, 95% CI 1.08-3.42; p=0.015) and advanced age (OR 0.24, 95% CI 0.09-0.94; p=0.041) were significantly associated with the occurrence of PACE by multiple logistic regression analyses. CONCLUSIONS Preoperative serum leptin level and advanced age were two independent risk factors for PACE among elderly patients undergoing elective major non-cardiac surgery.

Management Strategies for Noncardiac Surgery Following a Coronary Artery Event

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.

Rosuvastatin Improves Vaspin Serum Levels in Obese Patients with Acute Coronary Syndrome

Adipose tissue-derived serine protease inhibitor (vaspin), which has endocrine and local roles in atherosclerosis growth, is also synthesized by adipose tissue; it was found that vaspin was negatively correlated with blood pressure in obese patients, while vaspin levels were decreased in endothelial dysfunction. The aim of the present study was to determine rosuvastatin modulation effects on serum vaspin levels in acute coronary syndrome (ACS) with class I obesity. A total number of seventy patients with acute coronary syndrome previously and currently treated with rosuvastatin was compared to 40 patients with IHD not treated by rosuvastatin as a control. Vaspin serum levels were higher in rosuvastatin-treated patients with acute coronary syndrome compared to the patients with acute coronary syndrome not treated by rosuvastatin, p < 0.01. Additionally, in the rosuvastatin-treated group, patients with STEMI showed higher vaspin serum levels compared to NSTEMI p < 0.01. Conclusion: Rosuvastatin significantly increases vaspin serum levels in acute coronary syndrome.

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

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.

Pleiotropic effects of statins in the perioperative setting

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.

Pharmacological treatment of vascular risk factors for reducing mortality and cardiovascular events in patients with abdominal aortic aneurysm

BACKGROUND

Pharmacological prophylaxis has been proven to reduce the risk of cardiovascular events in individuals with atherosclerotic occlusive arterial disease. However, the role of prophylaxis in individuals with abdominal aortic aneurysm (AAA) remains unclear. Several studies have shown that despite successful repair, those people with AAA have a poorer rate of survival than healthy controls. People with AAA have an increased prevalence of coronary heart disease and risk of cardiovascular events. Despite this association, little is known about the effectiveness of pharmacological prophylaxis in reducing cardiovascular risk in people with AAA. This is an update of a Cochrane review first published in 2014.

OBJECTIVES

To determine the long-term effectiveness of antiplatelet, antihypertensive or lipid-lowering medication in reducing mortality and cardiovascular events in people with abdominal aortic aneurysm (AAA).

SEARCH METHODS

For this update the Cochrane Vascular Information Specialist (CIS) searched the Cochrane Vascular Specialised Register (14 April 2016). In addition, the CIS searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 3) and trials registries (14 April 2016) and We also searched the reference lists of relevant articles.

SELECTION CRITERIA

Randomised controlled trials in which people with AAA were randomly allocated to one prophylactic treatment versus another, a different regimen of the same treatment, a placebo, or no treatment were eligible for inclusion in this review. Primary outcomes included all-cause mortality and cardiovascular mortality.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, and completed quality assessment and data extraction. We resolved any disagreements by discussion. Only one study met the inclusion criteria of the review, therefore we were unable to perform meta-analysis.

MAIN RESULTS

No new studies met the inclusion criteria for this update. We included one randomised controlled trial in the review. A subgroup of 227 participants with AAA received either metoprolol (N = 111) or placebo (N = 116). There was no clear evidence that metoprolol reduced all-cause mortality (odds ratio (OR) 0.17, 95% confidence interval (CI) 0.02 to 1.41), cardiovascular death (OR 0.20, 95% CI 0.02 to 1.76), AAA-related death (OR 1.05, 95% CI 0.06 to 16.92) or increased nonfatal cardiovascular events (OR 1.44, 95% CI 0.58 to 3.57) 30 days postoperatively. Furthermore, at six months postoperatively, estimated effects were compatible with benefit and harm for all-cause mortality (OR 0.71, 95% CI 0.26 to 1.95), cardiovascular death (OR 0.73, 95% CI 0.23 to 2.39) and nonfatal cardiovascular events (OR 1.41, 95% CI 0.59 to 3.35). Adverse drug effects were reported for the whole study population and were not available for the subgroup of participants with AAA. We considered the study to be at a generally low risk of bias. We downgraded the quality of the evidence for all outcomes to low. We downgraded the quality of evidence for imprecision as only one study with a small number of participants was available, the number of events was small and the result was consistent with benefit and harm.

AUTHORS' CONCLUSIONS

Due to the limited number of included trials, there is insufficient evidence to draw any conclusions about the effectiveness of cardiovascular prophylaxis in reducing mortality and cardiovascular events in people with AAA. Further good-quality randomised controlled trials that examine many types of prophylaxis with long-term follow-up are required before firm conclusions can be made.

Canadian Cardiovascular Society Guidelines on Perioperative Cardiac Risk Assessment and Management for Patients Who Undergo Noncardiac Surgery

The Canadian Cardiovascular Society Guidelines Committee and key Canadian opinion leaders believed there was a need for up to date guidelines that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system of evidence assessment for patients who undergo noncardiac surgery. Strong recommendations included: 1) measuring brain natriuretic peptide (BNP) or N-terminal fragment of proBNP (NT-proBNP) before surgery to enhance perioperative cardiac risk estimation in patients who are 65 years of age or older, are 45-64 years of age with significant cardiovascular disease, or have a Revised Cardiac Risk Index score ≥ 1; 2) against performing preoperative resting echocardiography, coronary computed tomography angiography, exercise or cardiopulmonary exercise testing, or pharmacological stress echocardiography or radionuclide imaging to enhance perioperative cardiac risk estimation; 3) against the initiation or continuation of acetylsalicylic acid for the prevention of perioperative cardiac events, except in patients with a recent coronary artery stent or who will undergo carotid endarterectomy; 4) against α₂ agonist or β-blocker initiation within 24 hours before surgery; 5) withholding angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker starting 24 hours before surgery; 6) facilitating smoking cessation before surgery; 7) measuring daily troponin for 48 to 72 hours after surgery in patients with an elevated NT-proBNP/BNP measurement before surgery or if there is no NT-proBNP/BNP measurement before surgery, in those who have a Revised Cardiac Risk Index score ≥1, age 45-64 years with significant cardiovascular disease, or age 65 years or older; and 8) initiating of long-term acetylsalicylic acid and statin therapy in patients who suffer myocardial injury/infarction after surgery.