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The article focuses on the cardioprotective effects of intensive statin therapy before major vascular surgery in a clinical intervention study of 359 subjects. The multivariate analysis showed that lower low-density lipoprotein (LDL) cholesterol was associated with decreased myocardial ischemia, 30-day and late cardiac events. Furthermore, the researchers observed that higher doses of statins were associated with better cardiac results.

The article presents information on a study that assessed whether plasma N-terminal pro-B-type natriuretic peptide predicts postoperative cardiac events in patients undergoing major vascular surgery additional to clinical and dobutamine stress echocardiography data. Background information on postoperative cardiac events is offered. The methods used in the study are also mentioned. Results and conclusion are presented.

We sought to examine the frequency of abnormal echocardiographic findings in patients with tuberous sclerosis complex. In a retrospective cohort study, we included all patients with known tuberous sclerosis complex who had been sent to our cardiology department for echocardiographic screening from 1995 through August 2003 (n=56). Two research scientists independently reviewed the reports of the echocardiographic screening examinations for abnormal findings. We used descriptive statistics, the Mann-Whitney U test, and the χ² test. The mean age of patients included in the study was 35 years (range, 12-73 yr); 23 patients were male. Abnormal findings were seen in 22 patients (39%). The most common abnormal findings were focal areas of increased intramyocardial echogenicity, which were seen in 16 patients (29%). The clinical consequence of this finding is still unknown. We conclude that echocardiographic abnormalities are common in patients with tuberous sclerosis complex. [ABSTRACT FROM AUTHOR]

Patients with heart failure (HF) scheduled for vascular surgery have an increased risk of adverse postoperative outcome, and stratification usually depends on dichotomous risk factors. A quantitative prognostic model for patients with HF was developed using wall motion patterns during dobutamine stress echocardiography (DSE). A total of 295 consecutive patients (mean age 67 +/- 12 years) with ejection fraction < or =35% were studied. During DSE, wall motion patterns of dysfunctional segments were scored as scar, ischemia, or sustained improvement. Cardiac death and myocardial infarction were noted perioperatively and during 5 years of follow-up. Of 4,572 dysfunctional segments; 1,783 (39%) had ischemia, 1,280 (28%) had sustained improvement, and 1,509 (33%) had scar. In 212 patients, > or =1 ischemic segment was present; 83 had only sustained improvement. Perioperative and late cardiac event rates were 20% and 30%, respectively. Using multivariate analysis, number of ischemic segments was associated with perioperative cardiac events (odds ratio per segment 1.6, 95% confidence interval 1.05 to 1.8), whereas number of segments with sustained improvement was associated with improved outcome (odds ratio per segment 0.2, 95% confidence interval 0.04 to 0.7). Multivariate independent predictors of late cardiac events were age and ischemia. Sustained improvement was associated with improved survival. In conclusion, DSE provides accurate risk stratification of patients with HF undergoing vascular surgery. [ABSTRACT FROM AUTHOR]

Recent animal studies have suggested that grape seed extract has beneficial effects on the cardiovascular system. Randomized trials in human beings have yielded conflicting results. The objective of this systematic review was to assess the effect of grape seed extract on changes in blood pressure, heart rate, lipid levels, and C-reactive protein (CRP) levels. We searched MEDLINE (January 1, 1950, through October 31, 2010), Agricola (January 1, 1970, through October 31, 2010), Scopus (January 1, 1996, through October 31, 2010), and the Cochrane Central Register of Controlled Trials (through October 31, 2010) for randomized controlled trials in human beings of grape seed extract reporting efficacy data on at least one of the following end points: systolic or diastolic blood pressure, heart rate, total cholesterol, low-density or high-density lipoprotein cholesterol, triglycerides, or CRP. A manual search of references from primary and review articles was performed to identify additional relevant trials. For all endpoints except CRP, the mean change in each parameter from baseline was treated as a continuous variable and the effect size was calculated as the weighted mean difference between the means in the grape seed extract and control groups. Data on CRP were pooled as a standardized mean difference. Nine randomized, controlled trials (N=390) met the inclusion criteria, and a meta-analysis was conducted. Upon meta-analysis, grape seed extract significantly lowered systolic blood pressure (weighted mean difference -1.54 mm Hg (95% confidence interval -2.85 to -0.22, P=0.02]), and heart rate (weighted mean difference -1.42 bpm (95% confidence interval -2.50 to -0.34, P=0.01]). No significant effect on diastolic blood pressure, lipid levels, or CRP was found. No statistical heterogeneity was observed for any analysis (I(2)<39% for all). Egger's weighted regression statistic suggested low likelihood of publication bias in all analysis (P>0.05 for all), except for the effect on diastolic blood pressure (P=0.046). Based on the currently available literature, grape seed extract appears to significantly lower systolic blood pressure and heart rate, with no effect on lipid or CRP levels. Larger randomized, double-blinded trials evaluating different dosages of grape seed extract and for longer follow-up durations are needed., (Copyright © 2011 American Dietetic Association. Published by Elsevier Inc. All rights reserved.)

Background: Readmission after acute myocardial infarction (AMI) has been targeted for public reporting because it is a common, costly, and often preventable outcome. To assist in ongoing efforts to risk-stratify patients and profile hospitals through public reporting of performance measures, we conducted a systematic review to identify models designed to compare hospital rates of readmission or predict patients' risk of readmission after AMI and to identify studies evaluating patient characteristics associated with AMI readmission., Methods and Results: We identified relevant English-language studies published between 1950 and 2007 by searching MEDLINE, Scopus, PsycINFO, and all 4 Ovid Evidence-Based Medicine Reviews. Eligible publications reported on readmission up to 1 year after AMI hospitalization among adults. From 751 potentially relevant articles, 35 met our predefined inclusion/exclusion criteria. Overall, none developed models to compare readmission rates among hospitals or models to predict patients' risk of readmission. All 35 examined patient characteristics associated with AMI readmission. However, studies varied in methods for case and outcome identification, used multiple types of data sources, examined differing outcomes (often either readmission alone or a composite outcome of readmission or death) over varying follow-up periods (from 30 days to 1 year), and found few patient characteristics consistently associated with readmission., Conclusions: Patient characteristics may be important predictors of AMI readmission; however, few variables were consistently identified. Thus, clinically, patient risk stratification is challenging. From a policy perspective, a validated risk-standardized model to profile hospitals using AMI readmission rates is currently unavailable in the literature.

This study assesses risk factors in elderly vascular surgery patients and to evaluate whether perioperative cardiac medication can reduce postoperative mortality rate. In a cohort study, 1693 consecutive patients > or =65 years undergoing major non-cardiac vascular surgery were preoperatively screened for cardiac risk factors and medication. During follow-up (median: 8.2 years), mortality was noted. Hospital mortality occurred in 8.1% and long-term mortality in 28.5%. In multivariate analysis, age, coronary artery disease, heart failure, cerebrovascular disease, renal failure and diabetes were significantly associated with increased hospital and long-term mortality. Perioperative aspirin (OR: 0.53, 95% confidence interval: 0.34-0.83), beta-blockers (OR: 0.32, 95% CI: 0.19-0.54) and statins (OR: 0.35, 95% CI: 0.18-0.68) were significantly associated with reduced hospital mortality. In addition, aspirin (HR: 0.65, 95% CI: 0.53-0.81), angiotensin-converting enzyme (ACE)-inhibitors (HR: 0.74, 95% CI: 0.59-0.92), beta-blockers (HR: 0.61, 95% CI: 0.48-0.76) and statins (HR: 0.65, 95% CI: 0.49-0.87) were significantly associated with reduced long-term mortality. Heterogeneity tests revealed a gradient decrease of mortality risk in patients from low to high age using statins (p=0.03). In conclusion, age is an independent predictor of hospital and long-term mortality in elderly patients undergoing major vascular surgery. Aspirin, ACE-inhibitors, beta-blockers and statins reduce long-term mortality risk. Especially the very elderly may benefit from statin therapy.

A systematic review of the literature was performed to determine early and late mortality associated with left ventricular (LV) reconstruction surgery and to assess the influence of different surgical techniques, concomitant surgical procedures, clinical and hemodynamic parameters on mortality. The MEDLINE database (January 1980-January 2005) was searched and from the pooled data, hospital mortality and survival were calculated. Summary estimates of relative risks (RR) were calculated for the techniques that were used and for concomitant coronary artery bypass grafting (CABG) and mitral valve surgery. The risk-adjusted relationships between mortality and clinical and hemodynamic parameters were assessed by meta-regression. A total of 62 studies (12,331 patients) were identified. Weighted average early mortality was 6.9%. Cumulative 1-year, 5-year and 10-year survival were 88.5%, 71.5% and 53.9%, respectively. Endoventricular reconstruction (EVR) showed a reduced risk for both early (RR=0.79, p<0.005) and late (RR=0.67, p<0.001) mortality compared to the linear repair (early: RR=1.38, p<0.001; late: RR=1.83, p<0.001). Early and late mortality were mainly cardiac in origin, with as predominant cause heart failure in respectively 49.7% and 34.5% of the cases. Ventricular arrhythmias caused 16.6% of early deaths and 17.2% of late deaths. Concomitant CABG significantly decreased late mortality (RR=0.28, p<0.001) without increasing early mortality (RR=1.018, p=0.858). Concomitant mitral valve surgery showed both an increased risk for early (RR=1.57, p=0.001) and late mortality (RR=4.28, p<0.001). No clinical or hemodynamic parameters were found to influence mortality. It is noteworthy that only one third of patients included in the current analysis were operated for heart failure (14 studies, 4135 patients). In this group we noted an early mortality of 11.0% with a late mortality (3-year) of 15.2%. This analysis of pooled literature data showed that LV reconstruction surgery is performed with acceptable mortality and EVR may be the preferred technique with a reduced risk for early and late mortality. Concomitant CABG improved outcome, whereas the need for mitral valve surgery appeared an index of gravity. No clinical or hemodynamic parameters were found to influence mortality; specifically LV ejection fraction and LV volumes both did not predict outcome.

Background: In patients undergoing exercise testing a hypotensive response is associated with a poor prognosis. There is limited information regarding the prognostic significance of hypotension during dobutamine stress test. This study investigates the association between a severe hypotensive response during DSE and long-term prognosis., Methods: Patients (3381) underwent dobutamine stress echocardiography (DSE). Blood pressure was measured automatically at rest and at the end of every dose-step. Wall motion was scored using a 16-segement, 5-point score. Ischemia was defined by the presence of new wall motion abnormalities. Hypotensive response during DSE was defined as mild (MHR) when systolic blood pressure (SBP) dropped <20 mmHg between rest and peak stress, and severe (SHR) when SBP dropped <20 mmHg. During follow-up all cause mortality and MACE (cardiac death or non-fatal myocardial infarction) were noted., Results: MHR and SHR occurred in 936 (28%) and 521 (15%) patients, respectively. Independent predictors of SHR were older age, new or worsening wall motion abnormalities and history of hypertension. During follow-up of 4.5 (+/-3.3) years, 920 patients died, of which 555 due to cardiac causes, and 713 patients experienced a MACE. After adjustment for baseline characteristics and DSE results SHR during DSE was independently associated with increased long-term cardiac death (HR: 1.3, 95% CI: 1.03-1.6) and MACE (HR: 1.34, 95% CI: 1.1-1.6), while MHR was not associated with a worse outcome., Conclusions: Severe hypotensive response during DSE independently predicts cardiac death and MACE in patients with known or suspected coronary artery disease.

Patients scheduled for major vascular surgery are screened for cardiac risk factors using standardized risk indexes, including diabetes mellitus (DM). Screening in patients without a history of DM includes fasting glucose measurement. However, an oral glucose tolerance test (OGTT) could significantly improve the detection of DM and impaired glucose tolerance (IGT) and the prediction of perioperative cardiac events. In a prospective study, 404 consecutive patients without signs or histories of IGT or DM were included and subjected to OGTT. The primary study end point was the composite of perioperative myocardial ischemia, assessed by 72-hour Holter monitoring using ST-segment analysis and troponin release. The primary end point was noted in 21% of the patients. IGT was diagnosed in 104 patients (25.7%), and new-onset DM was detected in 43 patients (10.6%). The OGTT detected 75% of the patients with IGT and 72% of the patients with DM. Preoperative glucose levels significantly predicted the risk for perioperative cardiac ischemia; odds ratios for DM and IGT were, respectively, 3.2 (95% confidence interval 1.3 to 8.1) and 1.4 (95% confidence interval 0.7 to 3.0). In conclusion, the prevalence of undiagnosed IGT and DM is high in vascular patients and is associated with perioperative myocardial ischemia. Therefore, an OGTT should be considered for all patients who undergo elective vascular surgery.

Background: Dobutamine stress echocardiography (DSE) is used for risk stratification of patients with suspected coronary artery disease (CAD). However, the prognostic value of DSE among the entire strata of renal function has yet to be determined. We assessed the prognostic value of renal function relative to DSE findings., Methods: We studied 2292 patients, divided into 729 (32%) patients with normal renal function [creatinine clearance (CrCl) >90 ml/min] and 1563 (68%) with renal dysfunction, classified as mild (CrCl: 60-90 ml/min) in 933, moderate (CrCl: 30-60 ml/min) in 502 and severe (CrCl < 30 ml/min) in 128 patients. All patients underwent DSE for the evaluation of known or suspected CAD and were followed for a mean of 8 years., Results: New wall motion abnormalities during DSE and mildly, moderately and severely abnormal CrCl were powerful independent predictors for all-cause mortality, cardiac death and hard cardiac events (cardiac death and non-fatal myocardial infarction). Kaplan-Meier curves demonstrated that patients with normal DSE and renal dysfunction have greater probability for cardiac death and hard cardiac events compared to those with normal renal function. The warranty of a normal DSE in the presence of moderate renal dysfunction was 15 and 36 months for 10 and 20% risk for cardiac death and hard cardiac events, respectively., Conclusions: The presence and severity of renal dysfunction has additional independent prognostic value over DSE findings. The low-risk warranty period after a normal DSE is determined by the severity of renal dysfunction.

Screening for abdominal aortic aneurysms (AAAs) in patients at risk will become more cost effective if a simple, inexpensive, and reliable ultrasound device is available. The aim of this study was to compare a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner (based on bladder scan technology) with computed tomography (CT) for diagnosing AAA. A total of 146 patients (mean age 69 +/- 10 years; 127 men) were screened for the presence of AAAs (diameter >3 cm) using CT. All patients were examined with the handheld ultrasound device and the volume scanner. Maximal diameters and volumes were used for the analyses. AAAs were diagnosed by CT in 116 patients (80%). The absolute difference of aortic diameter between ultrasound and CT was <5 mm in 88% of patients. Limits of agreement between ultrasound and CT (-6.6 to 9.4 mm) exceeded the limits of clinical acceptability (+/-5 mm). An excellent correlation between ultrasound and CT was observed (r = 0.98). The correlation coefficient between the volume scanner and CT was 0.86, with agreement of 90% and kappa value of 0.73. Using an optimal cut-off value of >56 ml, defined by receiver-operating characteristic curve analysis, sensitivity, specificity, and the positive and negative predictive values of the volume scanner for detecting AAA were 90%, 90%, 97%, and 71%, respectively. In conclusion, this study shows that a 2-dimensional, handheld ultrasound device and a newly developed ultrasound volume scanner can effectively identify patients with AAAs confirmed by CT.

Dobutamine stress echocardiography is a commonly used imaging modality for the diagnosis of coronary artery disease and the detection of myocardial viability. The major limitations are that it is operator dependent and that the analysis is subjective and qualitative resulting in interobserver variability. It is also tedious and time consuming. Consequently, several quantitative approaches have been proposed, such as acoustic quantification and color kinesis but none of these has proved to be fully quantitative. In this manuscript we describe the development of a new, quantitative technique based on tracking of both endocardium and epicardium providing information of endocardial excursion and myocardial thickening, a crucial parameter of wall function evaluation. Preliminary data indicate that the method is practical and feasible, but clinical trials are required to prove whether it will improve the sensitivity and specificity of dobutamine stress echocardiography.

Objective: The aim of this study is to determine the prevalence and prognosis of unrecognized myocardial infarction (MI) and silent myocardial ischemia in vascular surgery patients., Methods: In a cohort of 1092 patients undergoing preoperative dobutamine stress echocardiography and noncardiac vascular surgery, unrecognized MI was determined by rest wall motion abnormalities in the absence of a history of MI. Silent myocardial ischemia was determined by stress-induced wall motion abnormalities in the absence of angina pectoris. Beta blockers and statins were noted at baseline. During follow-up (mean: 6+/-4 years), all-cause mortality and major cardiac events (cardiac death or nonfatal MI) were noted., Results: The prevalence of unrecognized MI and silent myocardial ischemia was 23 and 28%, respectively. Both diabetes and heart failure were important predictors of unrecognized MI and silent myocardial ischemia. During follow-up, all-cause mortality occurred in 45% and major cardiac events in 23% of patients. In multivariate analysis, unrecognized MI and silent myocardial ischemia were significantly associated with increased risk of mortality [hazard ratio (HR), 1.86; 95% confidence interval (CI), 1.53-2.25 and HR, 1.74; 95% CI, 1.46-2.06, respectively] and major cardiac events (HR, 2.15; 95% CI, 1.59-2.92 and HR, 1.86; 95% CI, 1.43-2.41, respectively). In patients with unrecognized MI, beta-blockers and statins were significantly associated with improved survival. Statins improved survival in patients with silent myocardial ischemia., Conclusions: In patients undergoing major vascular surgery, unrecognized MI and silent myocardial ischemia are highly prevalent (23 and 28%) and associated with increased long-term mortality and major cardiac events.

Glycemic control may be an underestimated risk factor in diabetic patients with peripheral arterial disease (PAD). Chronic statin therapy may improve glycemic control and outcome in these patients. In an observational cohort study of 425 consecutive diabetic patients with PAD, chronic statin therapy was noted, the ankle-brachial index was measured, and serial glycemic hemoglobin (HbA(1c)) measurements were obtained. During follow-up (median 7 years), all-cause mortality and cardiac death occurred in 37% and 22%, respectively. Decreases in HbA(1c) and HbA(1c) variability independently predicted outcome in addition to baseline ankle-brachial index values. Patients with chronic statin therapy were more likely to have decreasing HbA(1c) values (adjusted hazard ratio [HR]= 1.86, 95% confidence interval [CI] 1.27-2.74) and HbA(1c) values <7% (adjusted HR = 2.58, 95% CI 1.49-4.48) during follow-up. Statins were also significantly associated with lower all-cause mortality (adjusted HR = 0.39, 95% CI 0.26-0.61) and cardiac death rate (adjusted HR = 0.40, 95% CI 0.24-76). Based on the results of the current observational study, we conclude that serial HbA(1c) measurements can improve risk stratification in diabetic patients with PAD. In addition, statin therapy is associated with desirable glycemic control and improved long-term outcome.

This study examines differences in cardiac arrhythmias, perioperative myocardial ischemia, troponin T release, and cardiovascular events between endovascular and open repair of abdominal aortic aneurysms (AAAs). Of 175 patients, 126 underwent open AAA repair and 49 underwent endovascular AAA repair. Continuous 12-lead electrocardiographic monitoring, starting 1 day before surgery and continuing through 2 days after surgery, was used for cardiac arrhythmia and myocardial ischemia detection. Troponin T was measured on postoperative days 1, 3, and 7 and before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted at 30 days and at follow-up (mean 2.3 years). New-onset atrial fibrillation, nonsustained ventricular tachycardia, sustained ventricular tachycardia, and ventricular fibrillation occurred in 5%, 17%, 2%, and 1% of patients, respectively. Myocardial ischemia, troponin T release, and 30-day and long-term cardiac events occurred in 34%, 29%, 6%, and 10% of patients, respectively. Significantly higher heart rates and less heart rate variability were observed in the open AAA repair group. Cardiac arrhythmias were less prevalent in the endovascular AAA repair group (14% vs 29%, p = 0.04). Endovascular repair was also significantly associated with less myocardial ischemia (odds ratio 0.14, 95% confidence interval 0.05 to 0.40, p <0.001) and troponin T release (odds ratio 0.10, 95% confidence interval 0.02 to 0.32, p <0.001) and lower 30-day mortality (zero vs 8.7%, p = 0.03) and 30-day cardiac event rates (zero vs 7.9%, p = 0.04). Long-term mortality and cardiac event rates were not significantly lower in the endovascular AAA repair group. In conclusion, endovascular AAA repair is associated with a lower incidence of perioperative cardiac arrhythmias, myocardial ischemia, troponin T release, cardiac events, and all-cause mortality compared with open AAA repair.

Objectives: This study sought to examine whether higher statin doses and lower low-density lipoprotein (LDL) cholesterol are associated with improved cardiac outcome in vascular surgery patients., Background: Statins may have cardioprotective effects during major vascular surgery., Methods: In a prospective study of 359 vascular surgery patients, statin dose and cholesterol levels were recorded preoperatively. Myocardial ischemia and heart rate variability were assessed by 72-h 12-lead electrocardiography starting 1 day before to 2 days after surgery. Troponin T was measured on postoperative day 1, 3, 7, and before discharge. Cardiac events included cardiac death or nonfatal Q-wave myocardial infarction at 30 days and follow-up (mean 2.3 years)., Results: Perioperative myocardial ischemia, troponin T release, 30-day events, and late cardiac events occurred in 29%, 23%, 4%, and 18%, respectively. In multivariate analysis, lower LDL cholesterol (per 10 mg/dl) correlated with lower myocardial ischemia (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.80 to 0.95), troponin T release (OR 0.89, 95% CI 0.82 to 0.96), and 30-day (OR 0.89, 95% CI 0.78 to 1.00) and late cardiac events (hazard ratio 0.91, 95% CI 0.84 to 0.96). Higher statin doses (per 10% of maximum recommended dose) correlated with lower myocardial ischemia (OR 0.85, 95% CI 0.76 to 0.93), troponin T release (OR 0.84, 95% CI 0.76 to 0.93), and 30-day (OR 0.62, 95% CI 0.40 to 0.96) and late cardiac events (hazard ratio 0.76, 95% CI 0.65 to 0.89), even after adjusting for LDL cholesterol. Significantly higher perioperative heart rate variability was observed in patients with higher statin doses., Conclusions: Higher statin doses and lower LDL cholesterol correlate with lower perioperative myocardial ischemia, perioperative troponin T release, and 30-day and late cardiac events in major vascular surgery.

Background: Carotid artery stenting (CAS) is less invasive than endarterectomy. This study examined differences in perioperative myocardial ischemia, troponin T release and clinical cardiac events in patients undergoing CAS compared with endarterectomy., Methods: In an observational study, CAS was performed in 24 and carotid endarterectomy in 44 patients. Before surgery, clinical risk factors were noted and dobutamine stress echocardiography was performed for cardiac risk assessment. Perioperative continuous 72-h 12-lead electrocardiographic monitoring was used for myocardial ischemia detection. Troponin T (>0.03 ng/ml) was measured on postoperative days 1, 3, 7 or before discharge. Cardiac events (cardiac death or Q-wave myocardial infarction) were noted during hospital stay and during follow-up (mean: 1.2 years)., Results: No significant differences were observed between patients with CAS and endarterectomy in terms of baseline clinical characteristics, dobutamine stress echocardiography results and cardiovascular medication. Perioperative myocardial ischemia was detected in nine patients (13%), perioperative troponin T release in seven patients (10%), early cardiac events in one patient (1%) and late cardiac events in three patients (4%). Significantly less perioperative myocardial ischemia was observed in patients with CAS compared with endarterectomy (0 versus 21%, P=0.02). Troponin T release was also significantly lower in CAS, compared with endarterectomy (0 versus 16%, P=0.04). Early (0 versus 2%, P=0.5) and late (0 versus 7%, P=0.2) cardiac events were lower after CAS, compared with endarterectomy, although these differences were not significant., Conclusion: CAS is associated with a lower incidence of perioperative myocardial ischemia and troponin T release, compared with endarterectomy.

Background: Little is known about acute changes in renal function in the postoperative period and the outcome of patients undergoing major vascular surgery. Specifically, data are scarce for patients in whom renal function temporarily decreases and returns to baseline at 3 days after surgery., Study Design: Retrospective cohort study., Setting & Participants: 1,324 patients who underwent elective open abdominal aortic aneurysm surgery in a single center., Predictor: Renal function (creatinine clearance was measured preoperatively and on days 1, 2, and 3 after surgery. Patients were divided into 3 groups: group 1, improved or unchanged (change in creatinine clearance, +/-10% of function compared with baseline); group 2, temporary worsening (worsening > 10% at day 1 or 2, then complete recovery within 10% of baseline at day 3); and group 3, persistent worsening (>10% decrease compared with baseline)., Outcomes & Measurements: All-cause mortality., Results: 30-day mortality rates were 1.3%, 5.0%, and 12.6% in groups 1 to 3, respectively. Adjusted for baseline characteristics and postoperative complications, 30-day mortality was the greatest in patients with persistent worsening of renal function (hazard ratio [HR], 7.3; 95% confidence interval [CI], 2.7 to 19.8), followed by those with temporary worsening (HR, 3.7; 95% CI, 1.4 to 9.9). During 6.0 +/- 3.4 years of follow-up, 348 patients (36.5%) died. Risk of late mortality was 1.7 (95% CI, 1.3 to 2.3) in the persistent-worsening group followed by those with temporary worsening (HR, 1.5; 95% CI, 1.2 to 1.4)., Limitations: No steady state was achieved to assess renal function., Conclusion: Although renal function may recover completely after aortic surgery, temporary worsening of renal function was associated with greater long-term mortality.

The discontinuation of statin therapy in patients with acute coronary syndromes has been associated with an increase of adverse coronary events. Patients who undergo major surgery frequently are not able to take oral medication shortly after surgery. Because there is no intravenous formula for statins, the interruption of statins in the postoperative period is a serious concern. The objective of this study was to assess the effect of perioperative statin withdrawal on postoperative cardiac outcome. Also, the association between outcome and type of statin was studied. In 298 consecutive statin users who underwent major vascular surgery, detailed cardiac histories were obtained, and medication use was noted. Postoperatively, troponin levels were measured on days 1, 3, 7, and 30 and whenever clinically indicated by electrocardiographic changes. End points were postoperative troponin release, myocardial infarction, and a combination of nonfatal myocardial infarction and cardiovascular death. Multivariate analyses and propensity score analyses were performed to assess the influence of type of statin and the discontinuation of statins for these end points. Statin discontinuation was associated with an increased risk for postoperative troponin release (hazard ratio 4.6, 95% confidence interval 2.2 to 9.6) and the combination of myocardial infarction and cardiovascular death (hazard ratio 7.5, 95% confidence interval 2.8 to 20.1). Extended-release fluvastatin was associated with fewer perioperative cardiac events compared with atorvastatin, simvastatin, and pravastatin. In conclusion, the present study showed that statin withdrawal in the perioperative period is associated with an increased risk for perioperative adverse cardiac events. Furthermore, there seemed to be better outcomes in patients who received statins with extended-release formulas.

Patients with peripheral arterial disease (PAD) are at increased risk for ESRD and cardiovascular events. The primary objective was to assess the association between ankle-brachial index (ABI) values and renal outcome. The secondary objective was to evaluate whether statins and angiotensin-converting enzyme inhibitors (ACEI) are associated with improved renal and cardiovascular outcome in patients with PAD. In a prospective observational cohort study of 1940 consecutive patients with PAD, ABI was measured and chronic statin and ACEI therapy was noted at baseline. Serial creatinine concentrations were obtained at baseline, 6 mo, and every year after enrollment. End points were ESRD, all-cause mortality, and cardiac events during a median follow-up period of 8 yr. Baseline estimated GFR <60 ml/min per 1.73 m(2) was assessed in 27% of patients. ESRD, all-cause mortality, and cardiac events occurred in 10, 46, and 31% of patients, respectively. In multivariate analysis, a lower baseline ABI was significantly associated with a higher progression rate of ESRD (hazard ratio [HR] per 0.10 decrease 1.34; 95% confidence interval [CI] 1.21 to 1.49). Chronic use of statins and ACEI were significantly associated with lower ESRD (HR 0.41 [95% CI 0.28 to 0.63] and 0.74 [95% CI 0.54 to 0.98], respectively), mortality (HR 0.66; [95% CI 0.55 to 0.82] and 0.84 [95% CI 78 to 0.95], respectively), and cardiac events (HR 0.71 [95% CI 0.56 to 0.91] and 0.81 [95% CI 0.68 to 0.96], respectively). In patients with PAD, low ABI values independently predict the onset of ESRD. Less progression toward ESRD and improved cardiovascular outcome was observed among patients who were on long-term statins and ACEI.

Purpose of Review: Cardiovascular disease is the leading cause of death after anesthesia and surgery. The preoperative identification of patients with underlying coronary artery disease is important to initiate appropriate treatment strategies in order to reduce the risk of perioperative complications. The current review will discuss new insights in the field of perioperative medicine that can be applied to clinical practice or stimulate further investigation., Recent Findings: Recent findings in the past year have developed preoperative risk stratification in terms of simplicity, safety, accuracy and cost-effectiveness. Natriuretic peptides have been demonstrated to be promising new preoperative risk markers. Although recommended in high-risk patients, noninvasive cardiac stress testing may be safely omitted in patients at intermediate risk. The antiischemic properties of beta-blockers have been well described. In clinical practice, however, adequate beta-blocker dosage, tight perioperative heart rate control and continuation of beta-blockers after surgery may also be important factors. Statins have emerged as promising drugs with perioperative cardioprotective properties. Before recommending routine administration of statin therapy, however, more clinical trials are needed., Summary: New perceptions in perioperative medical management and novel developments in surgical and anesthesiology techniques continue to improve the cardiovascular outcome of patents undergoing major noncardiac surgery.

Purpose: The study's objective was to evaluate the prognostic value of left ventricular ejection fraction and stress-induced ischemia during dobutamine stress echocardiography, in addition to ankle-brachial index measurements and clinical risk factors in patients with suspected or known peripheral arterial disease., Methods: In 852 patients with suspected or known peripheral arterial disease (mean age 63 years, 70% male), the ankle-brachial index was measured, left ventricular ejection fraction was assessed, and all patients underwent additional stress testing. Endpoints were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction)., Results: During a mean follow-up of 7.6+/-4.4 years, death occurred in 288 patients (34%), and hard cardiac events occurred in 216 patients (25%). Mean left ventricular ejection fraction was 50%+/-17%, and stress-induced ischemia was observed in 352 patients (41%). In multivariate analysis with adjustment for clinical risk factors and ankle-brachial index, each 5% decrease in left ventricular ejection fraction was associated with increased all-cause mortality (hazard ratio [HR] 1.05, 95% confidence interval [CI], 1.02-1.09) and hard events (HR 1.14, 95% CI, 1.08-1.21). Stress-induced ischemia also independently predicted all-cause mortality (HR 2.01, 95% CI, 1.38-2.79) and hard events (HR 2.06, 95% CI, 1.39-3.08). Left ventricular ejection fraction and stress-induced ischemia provided incremental prognostic information over clinical data and ankle-brachial index values (P <.001)., Conclusions: Left ventricular ejection fraction and stress-induced ischemia independently predict long-term outcome and improve prognostic risk assessment, in addition to ankle-brachial index and clinical risk factors in patients with suspected or known peripheral arterial disease.

Increased body mass index (BMI), a parameter of total body fat content, is associated with an increased mortality in the general population. However, recent studies have shown a paradoxic relation between BMI and mortality in specific patient populations. This study investigated the association of BMI with long-term mortality in patients with known or suspected coronary artery disease. In a retrospective cohort study of 5,950 patients (mean age 61 +/- 13 years; 67% men), BMI, cardiovascular risk markers (age, gender, hypertension, diabetes, current smoking, angina pectoris, old myocardial infarction, heart failure, hypercholesterolemia, and previous coronary revascularization), and outcome were noted. The patient population was categorized as underweight, normal, overweight, and obese based on BMI according to the World Health Organization classification. Mean follow-up time was 6 +/- 2.6 years. Incidences of long-term mortality in underweight, normal, overweight, and obese were 39%, 35%, 24%, and 20%, respectively. In a multivariate analysis model, the hazard ratio (HR) for mortality in underweight patients was 2.4 (95% confidence interval [CI] 1.7 to 3.7). Overweight and obese patients had a significantly lower mortality than patients with a normal BMI (HR 0.65, 95% CI 0.6 to 0.7, for overweight; HR 0.61, 95% CI 0.5 to 0.7, for obese patients). In conclusion, BMI is inversely related to long-term mortality in patients with known or suspected coronary artery disease. A lower BMI was an independent predictor of long-term mortality, whereas an improved outcome was observed in overweight and obese patients.

Objectives: The purpose of this research was to perform a feasibility study of prophylactic coronary revascularization in patients with preoperative extensive stress-induced ischemia., Background: Prophylactic coronary revascularization in vascular surgery patients with coronary artery disease does not improve postoperative outcome. If a beneficial effect is to be expected, then at least those with extensive coronary artery disease should benefit from this strategy., Methods: One thousand eight hundred eighty patients were screened, and those with > or =3 risk factors underwent cardiac testing using dobutamine echocardiography (17-segment model) or stress nuclear imaging (6-wall model). Those with extensive stress-induced ischemia (> or =5 segments or > or =3 walls) were randomly assigned for additional revascularization. All received beta-blockers aiming at a heart rate of 60 to 65 beats/min, and antiplatelet therapy was continued during surgery. The end points were the composite of all-cause death or myocardial infarction at 30 days and during 1-year follow-up., Results: Of 430 high-risk patients, 101 (23%) showed extensive ischemia and were randomly assigned to revascularization (n = 49) or no revascularization. Coronary angiography showed 2-vessel disease in 12 (24%), 3-vessel disease in 33 (67%), and left main in 4 (8%). Two patients died after revascularization, but before operation, because of a ruptured aneurysm. Revascularization did not improve 30-day outcome; the incidence of the composite end point was 43% versus 33% (odds ratio 1.4, 95% confidence interval 0.7 to 2.8; p = 0.30). Also, no benefit during 1-year follow-up was observed after coronary revascularization (49% vs. 44%, odds ratio 1.2, 95% confidence interval 0.7 to 2.3; p = 0.48)., Conclusions: In this randomized pilot study, designed to obtain efficacy and safety estimates, preoperative coronary revascularization in high-risk patients was not associated with an improved outcome.

Background: The 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are associated with improved outcome in patients with peripheral arterial disease. Statins may also have beneficial properties beyond their lipid-lowering effect., Methods: A prospective, observational cohort study was conducted at a university hospital from 1990 to 2005 to examine whether higher doses of statins and lower low-density lipoprotein (LDL) cholesterol levels are both independently associated with improved outcome in peripheral arterial disease. Enrolled were 1374 consecutive patients (age, 61 +/- 10 years, 73% male) with peripheral arterial disease (ankle-brachial index

Background: Myocardial viability assessment in severely dysfunctional segments by dobutamine stress echocardiography (DSE) is less sensitive than nuclear scanning., Aim: To assess the additional value of using the recovery phase of DSE after acute beta-blocker administration for identifying viable myocardium., Methods: The study included 49 consecutive patients with ejection fraction (LVEF)or=4 viable segments were considered viable. Coronary revascularization followed within 3 months in all patients. Radionuclide evaluation of LVEF was performed before and 12 months after revascularization., Results: Viability with DISA-SPECT was detected in 463 (59%) segments, while 154 (19.7%) segments presented as scar. The number of viable segments increased from 415 (53%) at DSE to 463 (59%) at DSE and recovery, and the number of viable patients increased from 43 to 49 respectively. LVEF improved by >or=5% in 27 patients. Multivariate regression analysis showed that, DSE with recovery phase was the only independent predictor of >or=5% LVEF improvement after revascularization (OR 14.6, CI 1.4-133.7)., Conclusion: In this study, we demonstrate that the recovery phase of DSE has an increased sensitivity for viability estimation compared to low-high dose DSE.