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Statin periomort

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Statin periomort

  1. 1. Statins are associated with aStatins are associated with a reduced incidence of perioperativereduced incidence of perioperative mortality in patients undergoingmortality in patients undergoing major vascular surgerymajor vascular surgery Poldermans D, Bax JJ, Kertai MD, Krenning B, Westerhout CW, Schinkel AF, Thomson IR, Lansberg PJ, Fleisher LA, Klein J, van Urk H, Roelandt JRTC, Boersma E Erasmus MC, Departments of Cardiology and Anaesthesiology
  2. 2. Increased plaque rupture and thrombus formation due to the stress response to surgery on hemodynamically (in)-significant coronary stenosis hemodynamic stress, vasospasm, fibrinolytic activity, platelet activation, hypercoagulability Sustained ischemia myocardial supply : demand - mismatch Pathophysiology of perioperative MIPathophysiology of perioperative MI Poldermans et al., Circulation 2003; 107: 1848-1851
  3. 3. Perioperative cardiac risk managementPerioperative cardiac risk management Beta-blockers reduction in perioperative cardiac death and MI Alpha 2 – adrenergic agonists Mivazerol associated with a lower incidence of MI and death from cardiac causes Nitroglycerin/diltiazem lack of sufficent evidence about their beneficial effect Coronary reavscularization is appropriate if indicated independently of the need for surgery Poldermans et al., Circulation 2003; 107: 1848-1851
  4. 4. 1065 patients underwent elective major vascular surgery between 1989-2001 at the EMCR Inclusion criteria: preoperative DSE, died within 30 days after surgery, autopsy DSE: presence and location of ischemia LAD / LCX / RCA territory Location of MI at autopsy Can dobutamine echocardiographyCan dobutamine echocardiography predict the location of perioperativepredict the location of perioperative infarction?infarction? Poldermans et al., Circulation 2003; 107: 1848-1851
  5. 5. Patients N = 32 Preoperative ischemia in 16 patients, in 7 (44%) in more than one coronary territory All patients experienced cardiac death MI was located outside the territory at risk defined by DSE in 8 /16 (50%) patients Can dobutamine echocardiographyCan dobutamine echocardiography predict the location of perioperativepredict the location of perioperative MI?MI? Poldermans et al., Circulation 2003; 107: 1848-1851
  6. 6. BackgroundBackground Patient undergoing major vascular surgery are at increased risk of perioperative mortality due to underlying coronary artery disease Inhibitors of the 3-hydroxy-3-methylglutaryl coenzyme A (statins) may reduce perioperative mortality through the improvement of lipid profile through the stabilization of coronary plaques on the vascular wall Poldermans et al., Circulation 2003; 107: 1848-1851
  7. 7. AimAim To evaluate the association between statin use and perioperative mortality in patient undergoing major vascular surgery Poldermans et al., Circulation 2003; 107: 1848-1851
  8. 8. Study DesignStudy Design • retrospective case-control study among of 2816 patients aged 18 years or older • scheduled for acute or elective abdominal aortic repair, carotid endarterectomy, or lower extremity revascularization Poldermans et al., Circulation 2003; 107: 1848-1851
  9. 9. Selection of cases and controlsSelection of cases and controls • cases: 160 patients who died due to any cause during surgery or during the hospital stay following surgery controls: two per each case; patients who were operated immediately before and after the case, stratified according to type of surgery, calendar year Poldermans et al., Circulation 2003; 107: 1848-1851
  10. 10. Data CollectionData Collection • information on cardiac risk factors (diabetes mellitus, angina pectoris, myocardial infarction, heart failure, renal failure, stroke) the most recent measurements of total and LDL cholesterol within 3 months prior to surgery Poldermans et al., Circulation 2003; 107: 1848-1851
  11. 11. Results – Table 1Results – Table 1 Characteristics Cases (N=160), [%] Controls (N=320), [%] P-Value Age 72 (66-77) 69 (62-75) <0.001 COPD 58 (36) 64 (20) <0.001 Renal failure 34 (21) 37 (12) 0.005 Angina pectoris 55 (34) 76 (24) 0.01 Myocardial infarction 84 (53) 109 (34) <0.001 Heart failure 44 (28) 35 (11) <0.001 Stroke 35 (22) 29 (9) <0.001 Type of surgery 1.0 Poldermans et al., Circulation 2003; 107: 1848-1851
  12. 12. Complications during theComplications during the perioperative phaseperioperative phase • Vascular complications n=104 (65%)Vascular complications n=104 (65%) fatal MI n=88 (56%) fatal stroke n=14 (9%) • Non-vascular complicationsNon-vascular complications bleeding n=21 (13%) sepsis n=30 (19%) Poldermans et al., Circulation 2003; 107: 1848-1851
  13. 13. Statin use in relation to mortalityStatin use in relation to mortality 0% 20% 40% 60% 80% 100% Cases Controls Odds Ratio = 0.22 (0.10-0.47) Statin users Non-users Poldermans et al., Circulation 2003; 107: 1848-1851
  14. 14. Beta-blocker use in relation toBeta-blocker use in relation to mortalitymortality 0% 20% 40% 60% 80% 100% Cases Controls Odds Ratio = 0.43 (0.26-0.72) Beta-blocker use Non-users Poldermans et al., Circulation 2003; 107: 1848-1851
  15. 15. Perioperative mortality in relation toPerioperative mortality in relation to statin usestatin use 0.01 0.1 1 10 No. of risk factors 0 or 1 2 3 or more Beta-blocker use No Yes Poldermans et al., Circulation 2003; 107: 1848-1851
  16. 16. ConclusionsConclusions • statin use reduced perioperative mortality • patients on statin therapy had a more than four-fold reduced risk • the results were consistent regardless of the type of surgery, cardiac risk factors, and beta- blocker use Poldermans et al., Circulation 2003; 107: 1848-1851

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