Aprotinin plus ACE inhibitors during off-pump surgery linked to renal dysfunction
By Sara Carrillo de Albornoz
08 February 2008
The Lancet 2008; 371: 475-482
MedWire News: Patients undergoing off-pump cardiac surgery who are treated with aprotinin and preoperative angiotensin-converting enzyme (ACE) inhibitors are at high risk for postoperative renal dysfunction, UK researchers report in The Lancet.
"We recommend that it might be beneficial for patients to discontinue any use of an ACE inhibitor before undergoing elective off-pump cardiac surgery, particularly patients with a history of renal impairment," say Kai Zacharowski and colleagues from the Bristol Royal Infirmary.
Aprotinin is an antifibrinolytic serine protease inhibitor that reduces peri-operative bleeding and decreases the need for blood transfusion and re-operation in patients undergoing cardiac surgery, but concerns have been raised about its role in renal impairment, the authors comment.
Zacharowski and team examined the association between aprotinin and renal dysfunction in 9012 patients undergoing cardiac surgery, of whom 5434 were operated on-pump and 3672 off-pump.
They separately analyzed the incidence of renal dysfunction in patients treated with aprotinin, tranexamic acid, or no antifibrinolytic therapy in combination with or without pre-operative ACE inhibitors.
After propensity adjustment, only patients undergoing off-pump surgery and treated with both ACE inhibitors and aprotinin were at high risk for postoperative renal dysfunction (odds ratio=2.87, p=0.013).
Among patients undergoing on-pump surgery, aprotinin - with or without ACE inhibitors - did not significantly increase the risk for renal dysfunction.
Zacharowski and co-workers conclude: "Our results have shown that aprotinin seems to be safe during on-pump cardiac surgery.
"However, the combination of aprotinin and ACE inhibitors during off -pump cardiac surgery is associated with a significant risk of postoperative renal dysfunction."
They add: "The international communities of cardiac anesthesia and surgery face controversy regarding the use of aprotinin."
Journal
Showing posts with label Cardiac Surgery. Show all posts
Showing posts with label Cardiac Surgery. Show all posts
Friday, February 8, 2008
Thursday, June 14, 2007
Racial Disparities in Revascularization Remain Unexplained
Racial Disparities in Revascularization Remain Unexplained
Black patients are less likely than white patients to undergo revascularization for acute MI, reports a study in JAMA.
Researchers examined Medicare data from 2000 to 2005 on 1.2 million black and white beneficiaries admitted for MI. Overall, blacks were less likely than whites to undergo revascularization by the 30-day mark. When admitted to hospitals without revascularization capabilities, blacks were less likely to be transferred to hospitals with full services. And even after transfer, blacks were less likely to undergo revascularization. Mortality rates were similar in both groups at 30 days but were generally higher for blacks thereafter. The differences persisted after adjustment for sociodemographic factors, clinical characteristics, and distance from the hospital.
The authors conclude that the observed differences "could be due to unmeasured clinical or socioeconomic factors, patient preferences, and unmeasured aspects of medical decision making but are unlikely to be related to differences in access to hospitals performing revascularization procedures."
ABSTRACT:
Differences in Mortality and Use of Revascularization in Black and White Patients With Acute MI Admitted to Hospitals With and Without Revascularization Services
Ioana Popescu, MD, MPH; Mary S. Vaughan-Sarrazin, PhD; Gary E. Rosenthal, MD
JAMA. 2007;297:2489-2495.
Context Racial differences in the use of coronary revascularization after acute myocardial infarction (AMI) have been widely reported. However, few studies have examined patterns of care for AMI patients admitted to hospitals with and without revascularization services.
Objective To compare rates of hospital transfer, coronary revascularization, and mortality after AMI for black and white patients admitted to hospitals with and without revascularization services.
Design, Setting, and Participants Retrospective cohort study of 1 215 924 black and white Medicare beneficiaries aged 68 years and older, admitted with AMI between January 1, 2000, and June 30, 2005, to 4627 US hospitals with and without revascularization services.
Main Outcome Measures For patients admitted to nonrevascularization hospitals, transfer to another hospital with revascularization services; for all patients, risk-adjusted rates of 30-day coronary revascularization and 1-year mortality.
Results Black patients admitted to hospitals without revascularization were less likely (25.2% vs 31.0%; P<.001) to be transferred. Black patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3% vs 50.2% and 18.3% vs 25.9%; P<.001) and had higher 1-year mortality (35.3% vs 30.2% and 39.7% vs 37.6%; P<.001). After adjustment for sociodemographics, comorbidity, and illness severity, blacks remained less likely to be transferred (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.75-0.81; P<.001) and undergo revascularization (HR, 0.71; 95% CI, 0.69-0.74; P<.001; and HR, 0.68; 95% CI, 0.65-0.70; P<.001 in hospitals with and without revascularization, respectively). Risk-adjusted mortality was lower for blacks during the first 30 days after admission (HR, 0.91; 95% CI, 0.88-0.93; P<.001; and HR, 0.90; 95% CI, 0.87-0.92; P<.001 in hospitals with and without revascularization, respectively) but was higher (P<.001) thereafter.
Conclusions Black patients admitted to hospitals with and without coronary revascularization services are less likely to receive coronary revascularization. The higher long-term mortality of black patients may reflect the lower use of revascularization or other aspects of AMI care.
LINK: http://jama.ama-assn.org/cgi/content/abstract/297/22/2489
Black patients are less likely than white patients to undergo revascularization for acute MI, reports a study in JAMA.
Researchers examined Medicare data from 2000 to 2005 on 1.2 million black and white beneficiaries admitted for MI. Overall, blacks were less likely than whites to undergo revascularization by the 30-day mark. When admitted to hospitals without revascularization capabilities, blacks were less likely to be transferred to hospitals with full services. And even after transfer, blacks were less likely to undergo revascularization. Mortality rates were similar in both groups at 30 days but were generally higher for blacks thereafter. The differences persisted after adjustment for sociodemographic factors, clinical characteristics, and distance from the hospital.
The authors conclude that the observed differences "could be due to unmeasured clinical or socioeconomic factors, patient preferences, and unmeasured aspects of medical decision making but are unlikely to be related to differences in access to hospitals performing revascularization procedures."
ABSTRACT:
Differences in Mortality and Use of Revascularization in Black and White Patients With Acute MI Admitted to Hospitals With and Without Revascularization Services
Ioana Popescu, MD, MPH; Mary S. Vaughan-Sarrazin, PhD; Gary E. Rosenthal, MD
JAMA. 2007;297:2489-2495.
Context Racial differences in the use of coronary revascularization after acute myocardial infarction (AMI) have been widely reported. However, few studies have examined patterns of care for AMI patients admitted to hospitals with and without revascularization services.
Objective To compare rates of hospital transfer, coronary revascularization, and mortality after AMI for black and white patients admitted to hospitals with and without revascularization services.
Design, Setting, and Participants Retrospective cohort study of 1 215 924 black and white Medicare beneficiaries aged 68 years and older, admitted with AMI between January 1, 2000, and June 30, 2005, to 4627 US hospitals with and without revascularization services.
Main Outcome Measures For patients admitted to nonrevascularization hospitals, transfer to another hospital with revascularization services; for all patients, risk-adjusted rates of 30-day coronary revascularization and 1-year mortality.
Results Black patients admitted to hospitals without revascularization were less likely (25.2% vs 31.0%; P<.001) to be transferred. Black patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3% vs 50.2% and 18.3% vs 25.9%; P<.001) and had higher 1-year mortality (35.3% vs 30.2% and 39.7% vs 37.6%; P<.001). After adjustment for sociodemographics, comorbidity, and illness severity, blacks remained less likely to be transferred (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.75-0.81; P<.001) and undergo revascularization (HR, 0.71; 95% CI, 0.69-0.74; P<.001; and HR, 0.68; 95% CI, 0.65-0.70; P<.001 in hospitals with and without revascularization, respectively). Risk-adjusted mortality was lower for blacks during the first 30 days after admission (HR, 0.91; 95% CI, 0.88-0.93; P<.001; and HR, 0.90; 95% CI, 0.87-0.92; P<.001 in hospitals with and without revascularization, respectively) but was higher (P<.001) thereafter.
Conclusions Black patients admitted to hospitals with and without coronary revascularization services are less likely to receive coronary revascularization. The higher long-term mortality of black patients may reflect the lower use of revascularization or other aspects of AMI care.
LINK: http://jama.ama-assn.org/cgi/content/abstract/297/22/2489
Tuesday, April 24, 2007
Noncoronary vascular surgery in high-CV-risk patients: Add PCI or CABG?
Noncoronary vascular surgery in high-CV-risk patients: Add PCI or CABG?
April 20, 2007
Washington, DC - Perioperative PCI or CABG makes little clinical impact in high-cardiovascular-risk patients with ischemic heart disease who undergo major noncoronary vascular surgery, suggests a randomized but inconclusive study [1].
Designed to clarify feasibility and safety considerations for any future larger, definitive exploration of the strategy, the study wasn't statistically strong enough to show whether adding perioperative coronary revascularization makes a clinical difference, caution the authors, led by Dr Don Poldermans (Erasmus Medical Center, Rotterdam, the Netherlands).
But having set the stage for a larger trial, according to the group as well as an accompanying editorial [2], the pilot study raises questions about CV screening before noncardiac surgery and the clinical importance of any discovered coronary stenoses that would be targeted by perioperative revascularization as compared with, for example, vulnerable plaques that are angiographically invisible.
The trial's neutral findings may relate to histopathologic evidence "that the pathophysiology surrounding fatal MI in the perioperative period after noncardiac surgery often includes unstable plaque and plaque disruption," write the editorialists, Drs Mauro Moscucci and Noah Jones (University of Michigan, Ann Arbor). "Thus, it is possible that revascularization of stable coronary artery stenosis might not add significantly to the effect of optimal medical therapy, similar to what has been shown for other low-risk patients with stable coronary artery disease."
The findings from the fifth Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE-5) pilot study and its accompanying editorial are published online April 13, 2007 by the Journal of the American College of Cardiology. They follow similar results from the Coronary Artery Revascularization Prophylaxis (CARP) trial, published in 2004 and reported by heartwire at the time, that compared the invasive and conservative perioperative strategies in a lower-risk CAD population [3].
Conducted in four European countries and Brazil over five years ending in 2005, DECREASE-5 randomized 101 patients with CAD who were scheduled for open abdominal aortic or infrainguinal arterial surgeries to receive either perioperative PCI or CABG (32 and 17 patients, respectively) or medical therapy (52 patients). Patients had been required to have at least three major cardiac risk factors (eg, angina, evidence of prior MI or neurologic events, heart failure, diabetes, or renal dysfunction) as well as stress-test-documented myocardial ischemia. Beta blockers were initiated for any patient not already on them.
In the PCI/CABG group, two patients died from ruptured aortic aneurysms prior to their noncoronary surgical procedures, "consistent with the fact that urgent or emergency vascular surgery in unstable patients should not be delayed by revascularization," Moscucci and Jones caution.
Rates of the primary end point, a 30-day composite of all-cause mortality and nonfatal MI, were 43% and 33%, respectively (p=0.30). Even out to one year, the rates were similar, at 49% and 44%, respectively (p=0.48). Incidences of the primary-end-point components did not differ between the groups. None in the medical-management group required coronary revascularization within a year of the noncoronary vascular surgery.
As none of the conservatively managed patients underwent diagnostic catheterization, yet their outcomes were similar to those managed with PCI or CABG, write the editorialists, "effective beta blockade and medical therapy might be sufficient, raising the question of whether stable patients scheduled for major vascular surgery should even be screened with stress testing."
However, they conclude, "the debate on screening and revascularization for patients with peripheral arterial disease and scheduled for major vascular surgery continues to be far from settled." DECREASE-5 provided safety and sample-size information needed for a larger exploration of the issue, they write. "It is now time to move forward with such a trial."
Moscucci reports receiving consulting fees from Pfizer and Boston Scientific, lecture fees from Pfizer, and grant support from Cordis
Sources
1. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V pilot study. J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2006.11.052. Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcontent.onlinejacc.org.
2. Moscucci M, Jones N. Coronary revascularization before noncardiac vascular surgery: One more step forward in understanding its role. J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2007.01.068 . Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcontent.onlinejacc.org.
3. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Eng J Med 2004; 351:2795-2804.
Related links
Risk for death, stroke increased with combined CABG and CEA [Other News > Medscape Medical News; Jan 16, 2007]
Higher risk of stroke and death in patients undergoing combined CEA-CABG surgery vs CABG alone [HeartWire > Other News; Apr 25, 2005]
No benefit from revascularization before vascular surgery: CARP published [HeartWire > Other News; Dec 29, 2004]
April 20, 2007
Washington, DC - Perioperative PCI or CABG makes little clinical impact in high-cardiovascular-risk patients with ischemic heart disease who undergo major noncoronary vascular surgery, suggests a randomized but inconclusive study [1].
Designed to clarify feasibility and safety considerations for any future larger, definitive exploration of the strategy, the study wasn't statistically strong enough to show whether adding perioperative coronary revascularization makes a clinical difference, caution the authors, led by Dr Don Poldermans (Erasmus Medical Center, Rotterdam, the Netherlands).
But having set the stage for a larger trial, according to the group as well as an accompanying editorial [2], the pilot study raises questions about CV screening before noncardiac surgery and the clinical importance of any discovered coronary stenoses that would be targeted by perioperative revascularization as compared with, for example, vulnerable plaques that are angiographically invisible.
The trial's neutral findings may relate to histopathologic evidence "that the pathophysiology surrounding fatal MI in the perioperative period after noncardiac surgery often includes unstable plaque and plaque disruption," write the editorialists, Drs Mauro Moscucci and Noah Jones (University of Michigan, Ann Arbor). "Thus, it is possible that revascularization of stable coronary artery stenosis might not add significantly to the effect of optimal medical therapy, similar to what has been shown for other low-risk patients with stable coronary artery disease."
The findings from the fifth Dutch Echocardiographic Cardiac Risk Evaluation Applying Stress Echocardiography (DECREASE-5) pilot study and its accompanying editorial are published online April 13, 2007 by the Journal of the American College of Cardiology. They follow similar results from the Coronary Artery Revascularization Prophylaxis (CARP) trial, published in 2004 and reported by heartwire at the time, that compared the invasive and conservative perioperative strategies in a lower-risk CAD population [3].
Conducted in four European countries and Brazil over five years ending in 2005, DECREASE-5 randomized 101 patients with CAD who were scheduled for open abdominal aortic or infrainguinal arterial surgeries to receive either perioperative PCI or CABG (32 and 17 patients, respectively) or medical therapy (52 patients). Patients had been required to have at least three major cardiac risk factors (eg, angina, evidence of prior MI or neurologic events, heart failure, diabetes, or renal dysfunction) as well as stress-test-documented myocardial ischemia. Beta blockers were initiated for any patient not already on them.
In the PCI/CABG group, two patients died from ruptured aortic aneurysms prior to their noncoronary surgical procedures, "consistent with the fact that urgent or emergency vascular surgery in unstable patients should not be delayed by revascularization," Moscucci and Jones caution.
Rates of the primary end point, a 30-day composite of all-cause mortality and nonfatal MI, were 43% and 33%, respectively (p=0.30). Even out to one year, the rates were similar, at 49% and 44%, respectively (p=0.48). Incidences of the primary-end-point components did not differ between the groups. None in the medical-management group required coronary revascularization within a year of the noncoronary vascular surgery.
As none of the conservatively managed patients underwent diagnostic catheterization, yet their outcomes were similar to those managed with PCI or CABG, write the editorialists, "effective beta blockade and medical therapy might be sufficient, raising the question of whether stable patients scheduled for major vascular surgery should even be screened with stress testing."
However, they conclude, "the debate on screening and revascularization for patients with peripheral arterial disease and scheduled for major vascular surgery continues to be far from settled." DECREASE-5 provided safety and sample-size information needed for a larger exploration of the issue, they write. "It is now time to move forward with such a trial."
Moscucci reports receiving consulting fees from Pfizer and Boston Scientific, lecture fees from Pfizer, and grant support from Cordis
Sources
1. Poldermans D, Schouten O, Vidakovic R, et al. A clinical randomized trial to evaluate the safety of a noninvasive approach in high-risk patients undergoing major vascular surgery: The DECREASE-V pilot study. J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2006.11.052. Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcontent.onlinejacc.org.
2. Moscucci M, Jones N. Coronary revascularization before noncardiac vascular surgery: One more step forward in understanding its role. J Am Coll Cardiol 2007; DOI:10.1016/j.jacc.2007.01.068 . Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcontent.onlinejacc.org.
3. McFalls EO, Ward HB, Moritz TE, et al. Coronary-artery revascularization before elective major vascular surgery. N Eng J Med 2004; 351:2795-2804.
Related links
Risk for death, stroke increased with combined CABG and CEA [Other News > Medscape Medical News; Jan 16, 2007]
Higher risk of stroke and death in patients undergoing combined CEA-CABG surgery vs CABG alone [HeartWire > Other News; Apr 25, 2005]
No benefit from revascularization before vascular surgery: CARP published [HeartWire > Other News; Dec 29, 2004]
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