12 Aug 10
Posted in Anesthesia, Pre-operatie evaluation at 0:01 by Laci
By W Flu, J van Kuijk, S Hoeks, R Kuiper, O Schouten, D Goei, A Elhendy et al
Anesthesiology 2010;112:1316-1324
The prognostic value of heart failure symptoms on postoperative outcome is well acknowledged in perioperative guidelines. The prognostic value of asymptomatic left ventricular (LV) dysfunction remains unknown. This study evaluated the prognostic implications of asymptomatic LV dysfunction in vascular surgery patients assessed with routine echocardiography.
Methods
Echocardiography was performed preoperatively in 1,005 consecutive vascular surgery patients. Systolic LV dysfunction was defined as LV ejection fraction less than 50%. Ratio of mitral-peak velocity during early and late filling, pulmonary vein flow, and deceleration time was used to diagnose diastolic LV dysfunction. Troponin-T measurements and electrocardiograms were performed routinely perioperatively. Multivariate regression analyses evaluated the relation between LV function and the study endpoints, 30-day cardiovascular events, and long-term cardiovascular mortality.
Results
Left ventricular dysfunction was diagnosed in 506 (50%) patients of which 80% were asymptomatic. In open vascular surgery (n = 649), both asymptomatic systolic and isolated diastolic LV dysfunctions were associated with 30-day cardiovascular events (odds ratios 2.3, 95% confidence interval [CI] 1.4–3.6 and 1.8, 95% CI 1.1–2.9, respectively) and long-term cardiovascular mortality (hazard ratios 4.6, 95% CI 2.4–8.5 and 3.0, 95% CI 1.5–6.0, respectively). In endovascular surgery (n = 356), only symptomatic heart failure was associated with 30-day cardiovascular events (odds ratio 1.8, 95% CI 1.1–2.9) and long-term cardiovascular mortality (hazard ratio 10.3, 95% CI 5.4–19.3).
Conclusions
This study demonstrated that asymptomatic LV dysfunction is predictive for 30-day and long-term cardiovascular outcome in open vascular surgery patients. These data suggest that preoperative risk stratification should include not only solely heart failure symptoms but also routine preoperative echocardiography to risk stratify open vascular surgery patients.
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22 May 10
Posted in Anesthesia, Coronary artery disease, Pre-operatie evaluation at 19:54 by Laci
By N Cruden, S Harding, A Flapan, C Graham, S Wild, R Slack, J Pell, D Newby and on behalf of the Scottish Coronary Revascularisation Register Steering Committee
Circulation: Cardiovascular Interventions. Published Online on May 4, 2010
Noncardiac surgery performed after coronary stent implantation is associated with an increased risk of stent thrombosis, myocardial infarction, and death. The influence of stent type and period of risk still have to be defined.
Methods and results
We linked the Scottish Coronary Revascularisation Register with hospital admission data to undertake a Scotland-wide retrospective cohort study examining cardiac outcomes in all patients who received drug-eluting or bare-metal stents between April 2003 and March 2007 and subsequently underwent noncardiac surgery. Of 1953 patients, 570 (29%) were treated with at least 1 drug-eluting stent and 1383 (71%) with bare-metal stents only. There were no differences between drug-eluting and bare-metal stents in the primary end point of in-hospital mortality or ischemic cardiac events (14.6% versus 13.3%; P=0.3) or the secondary end points of in-hospital mortality (0.7% versus 0.6%; P=0.8) and acute myocardial infarction (1.2% versus 0.7%; P=0.3). Perioperative death and ischemic cardiac events occurred more frequently when surgery was performed within 42 days of stent implantation (42.4% versus 12.8% beyond 42 days; P<0.001), especially in patients revascularized after an acute coronary syndrome (65% versus 32%; P=0.037). There were no temporal differences in outcomes between the drug-eluting and bare-metal stent groups.
Conclusions
Patients undergoing noncardiac surgery after recent coronary stent implantation are at increased risk of perioperative myocardial ischemia, myocardial infarction, and death, particularly after an acute coronary syndrome. For at least 2 years after percutaneous coronary intervention, cardiac outcomes after noncardiac surgery are similar for both drug-eluting and bare-metal stents.
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09 Mar 10
Posted in Coronary artery disease, Pre-operatie evaluation at 1:55 by Laci
By F Fowkes, J Price, M Stewart, I Butcher, G Leng, A Pell, P Sandercock, K Fox, G Lowe, G Murray for the Aspirin for Asymptomatic Atherosclerosis Trialists
JAMA. 2010;303:841-848
A low ankle brachial index (ABI) indicates atherosclerosis and an increased risk of cardiovascular and cerebrovascular events. Screening for a low ABI can identify an asymptomatic higher risk group potentially amenable to preventive treatments.
Objective
To determine the effectiveness of aspirin in preventing events in people with a low ABI identified on screening the general population.
Design, setting and participants
The Aspirin for Asymptomatic Atherosclerosis trial was an intention-to-treat double-blind randomized controlled trial conducted from April 1998 to October 2008, involving 28 980 men and women aged 50 to 75 years living in central Scotland, free of clinical cardiovascular disease, recruited from a community health registry, and had an ABI screening test. Of those, 3350 with a low ABI (0.95) were entered into the trial, which was powered to detect a 25% proportional risk reduction in events.
Interventions
Once daily 100 mg aspirin (enteric coated) or placebo.
Main outcome measures
The primary end point was a composite of initial fatal or nonfatal coronary event or stroke or revascularization. Two secondary end points were (1) all initial vascular events defined as a composite of a primary end point event or angina, intermittent claudication, or transient ischemic attack; and (2) all-cause mortality.
Results
After a mean (SD) follow-up of 8.2 (1.6) years, 357 participants had a primary end point event (13.5 per 1000 person-years, 95% confidence interval [CI], 12.2-15.0). No statistically significant difference was found between groups (13.7 events per 1000 person-years in the aspirin group vs 13.3 in the placebo group; hazard ratio [HR], 1.03; 95% CI, 0.84-1.27). A vascular event comprising the secondary end point occurred in 578 participants (22.8 per 1000 person-years; 95% CI, 21.0-24.8) and no statistically significant difference between groups (22.8 events per 1000 person-years in the aspirin group vs 22.9 in the placebo group; HR, 1.00; 95% CI, 0.85-1.17). There was no significant difference in all-cause mortality between groups (176 vs 186 deaths, respectively; HR, 0.95; 95% CI, 0.77-1.16). An initial event of major hemorrhage requiring admission to hospital occurred in 34 participants (2.5 per 1000 person-years) in the aspirin group and 20 (1.5 per 1000 person-years) in the group (HR, 1.71; 95% CI, 0.99-2.97).
Conclusion
Among participants without clinical cardiovascular disease, identified with a low ABI based on screening a general population, the administration of aspirin compared with placebo did not result in a significant reduction in vascular events.
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24 Feb 10
Posted in Anesthesia, Pre-operatie evaluation, Venous thromboembolism at 12:17 by Laci
NICE clinical guideline CG92
This guidance is about the care and treatment of people who are at risk of developing deep vein thrombosis (DVT) while in hospital in the NHS in England and Wales.
The advice in the NICE guideline covers the care and treatment that should be offered to all adults (aged 18 and over) who are admitted to hospital as inpatients (including those admitted for day-case procedures).
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