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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22 Jan 10
Posted in Diabetes, Pre-operatie evaluation at 0:32 by Laci
By Y Hsin-Chieh, B Duncan, M Schmidt, N Wang F Brancati
Ann Int Med 2010;152:10-17
Cigarette smoking is an established predictor of incident type 2 diabetes mellitus, but the effects of smoking cessation on diabetes risk are unknown.
Objective
To test the hypothesis that smoking cessation increases diabetes risk in the short term, possibly owing to cessation-related weight gain.
Design
Prospective cohort study.
Setting
The ARIC (Atherosclerosis Risk in Communities) Study.
Patients
10 892 middle-aged adults who initially did not have diabetes in 1987 to 1989.
Measurements
Smoking was assessed by interview at baseline and at subsequent follow-up. Incident diabetes was ascertained by fasting glucose assays through 1998 and self-report of physician diagnosis or use of diabetes medications through 2004.
Results
During 9 years of follow-up, 1254 adults developed type 2 diabetes. Compared with adults who never smoked, the adjusted hazard ratio of incident diabetes in the highest tertile of pack-years was 1.42 (95% CI, 1.20 to 1.67). In the first 3 years of follow-up, 380 adults quit smoking. After adjustment for age, race, sex, education, adiposity, physical activity, lipid levels, blood pressure, and ARIC Study center, compared with adults who never smoked, the hazard ratios of diabetes among former smokers, new quitters, and continuing smokers were 1.22 (CI, 0.99 to 1.50), 1.73 (CI, 1.19 to 2.53), and 1.31 (CI, 1.04 to 1.65), respectively. Further adjustment for weight change and leukocyte count attenuated these risks substantially. In an analysis of long-term risk after quitting, the highest risk occurred in the first 3 years (hazard ratio, 1.91 [CI, 1.19 to 3.05]), then gradually decreased to 0 at 12 years.
Limitation
Residual confounding is possible even with meticulous adjustment for established diabetes risk factors.
Conclusion
Cigarette smoking predicts incident type 2 diabetes, but smoking cessation leads to higher short-term risk. For smokers at risk for diabetes, smoking cessation should be coupled with strategies for diabetes prevention and early detection.
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01 Jan 10
Posted in Anesthesia, Anticoagulation, Coronary artery disease, Pre-operatie evaluation at 16:19 by Laci
by P Chassot, A Delabays, D Spahn
Best Pract Res Clin Anaesthesiol 2007; 21:241–256
Performing a surgical procedure on a patient undergoing anti-platelet therapy raises a dilemma: is it safer to withdraw the drugs and reduce the haemorrhagic risk, or to maintain them and reduce the risk of myocardial ischaemic events? Based on recent clinical data, this review concludes that the risk of coronary thrombosis on anti-platelet drugs withdrawal is much higher than the risk of surgical bleeding when maintaining them. In secondary prevention, aspirin is a lifelong therapy and should never be stopped. Clopidogrel is mandatory as long as the coronary stents are not fully endothelialized, which takes 6–24 weeks depending on the technique used, but might be required for a longer period
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