Perioperative use of statins in noncardiac surgery

Statins as a Medical Adjunct in the Surgical Management of Chronic Subdural Hematomas

BACKGROUND

By stabilizing immature leaky vessel formation in neomembranes, statin drugs have been suggested as a nonsurgical treatment option for chronic subdural hematomas (cSDH). Statin therapy seems to reduce conservatively managed cSDH volume. However, the usefulness of these medications in supplementing surgical treatment is unknown.

OBJECTIVE

To investigate the effect of concurrent statin therapy on outcomes after surgical treatment of cSDH.

METHODS

A retrospective single-institution cohort study of surgically managed patients with convexity cSDH between 2009 and 2019 was conducted. Patients receiving this diagnosis who underwent surgical decompression were included, and those without follow-up scans were excluded. Demographic, clinical, and radiographic variables were collected. cSDH size was defined as maximum radial thickness in millimeters on axial computed tomography of the head. Multivariable linear regression was performed to identify factors (including statin use) that were associated with preoperative to follow-up cSDH size change.

RESULTS

Overall, 111 patients, including 36 patients taking statins on admission, were evaluated. Median time to follow-up postoperative imaging was 30 days (interquartile range, 17-42 days). Patients on statins were older (median, 75 years, range, 68-78.25 years vs. 69 years, range, 59-7 years; P = 0.006) and reported more antiplatelet use (67% vs. 28%; P < 0.001). Median change in follow-up size was 13 mm in both statin and nonstatin groups. Adjusting for other clinical covariates, statin use was associated with greater reduction in cSDH size (CE = -6.72 mm, 95% confidence interval, -13.18 to -0.26 mm; P = 0.042).

CONCLUSIONS

Statin use is associated with improved cSDH size postoperatively. Statin drugs might represent a low-cost and low-risk supplement to the surgical management for patients with cSDH.

Do statins, ACE inhibitors or sartans improve outcome in primary glioblastoma?

Glioblastomas are malignant brain tumors with poor prognosis. Lately, data from clinical studies assessing the role of co-medications in different cancer types suggested reduced mortality and potential anti-tumor activity for statins, angiotensin-I converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (sartans). Here, we analysed the association of co-treatment with statins, ACEI or sartans with outcome in a cohort of 810 patients enrolled in the phase III CENTRIC and phase II CORE trials on the role of the integrin antagonist, cilengitide, in newly diagnosed glioblastoma with or without O⁶-methylguanine DNA methyltransferase (MGMT) promoter methylation. Progression-free survival (PFS) and overall survival (OS) were analysed for each medication in the pooled patient group. No association was found for co-medication with either drug for PFS or OS. Median OS was 22.1 (statins) versus 22.2 (control) months (HR 1.06, 95% CI 0.81-1.39, p = 0.69), 20.4 (ACEI) versus 22.6 (control) months (HR 1.25, 95% CI 0.96-1.62, p = 0.10), and 21.7 (sartans) versus 22.3 (control) months (HR 0.86, 95% CI 0.61-1.21, p = 0.38). None of the comparisons showed a signal for different PFS or OS when analyses were controlled for MGMT promoter methylation or treatment group (TMZ/RT → TMZ vs. RT + CIL + TMZ → TMZ + CIL). This secondary analysis of two large glioblastoma trials thus was unable to detect evidence for an association of the use of statins, ACEI or sartans with outcome in patients with newly diagnosed glioblastoma. These data challenge the rationale for prospective studies on the possible role of these non-tumor-specific drugs within the concept of drug repurposing.

Pleiotropic effects of statins in the perioperative setting

Statins belong to a specific group of drugs that have been described for their ability to control hyperlipidemia as well as for other pleiotropic effects such as improving vascular endothelial function, inhibition of oxidative stress pathways, and anti-inflammatory actions. Accumulating clinical evidence strongly suggests that statins also have a beneficial effect on perioperative morbidity and mortality. Therefore, this review aims to present all recent and pooled data on statin treatment in the perioperative setting as well as to highlight considerations regarding their indications and therapeutic application.

Predictors of Restenosis After Carotid Endarterectomy

Introduction:

Carotid endarterectomy (CEA) is a well-established surgical technique in stroke prophylaxis. Long-term follow-up data on restenosis or recurrent neurological symptoms in Oriental patients are unclear.

Methods:

Patients’ notes from 1994 to 2011 were retrospectively reviewed and analyzed. A total of 301 cases of CEA were identified.

Results:

A lower restenosis rate was associated with the use of patch and never smokers in both univariate and multivariate analysis. Use of patch and never smokers were also found to be significantly associated with longer restenosis-free survival. Use of patch and postoperative use of statin were associated with better overall survival in both univariate and multivariate analysis.

Conclusion:

Use of patch and lack of smoking history are associated with less restenosis and longer restenosis-free survival. Use of patch and use of postoperative statin improves overall survival. Although restenosis after CEA is relatively common, reintervention was rarely necessary.

Patients transplanted for nonalcoholic steatohepatitis are at increased risk for postoperative cardiovascular events

Nonalcoholic steatohepatitis (NASH) is an independent predictor of coronary artery disease (CAD). Our aim was to compare the incidence of cardiovascular (CV) events between patients transplanted for NASH and alcohol (ETOH)-induced cirrhosis. This is a retrospective cohort study (August 1993 to March 2010) of 242 patients (115 NASH and 127 ETOH) with ≥12 months follow-up after liver transplantation (LT). Those with hepatocellular carcinoma or coexisting liver diseases were excluded. Kaplan-Meier's and Cox's proportional hazard analyses were conducted to compare survival. Logistic regression was used to calculate the likelihood of CV events, defined as death from any cardiac cause, myocardial infarction, acute heart failure, cardiac arrest, arrhythmia, complete heart block, and/or stroke requiring hospitalization <1 year after LT. Patients in the NASH group were older (58.4 versus 53.3 years) and were more likely to be female (45% versus 18%; P < 0.001). They were more likely to be morbidly obese (32% versus 9%), have dyslipidemia (25% versus 6%), or have hypertension (53% versus 38%; P < 0.01). On multivariate analysis, NASH patients were more likely to have a CV event <1 year after LT, compared to ETOH patients, even after controlling for recipient age, sex, smoking status, pretransplant diabetes, CV disease, and the presence of metabolic syndrome (26% versus 8%; odds ratio = 4.12; 95% confidence interval = 1.91-8.90). The majority (70%) of events occurred in the perioperative period, and the occurrence of a CV event was associated with a 50% overall mortality. However, there were no differences in patient, graft, or CV mortality between groups.

CONCLUSIONS

CV complications are common after LT, and NASH patients are at increased risk independent of traditional cardiac risk factors, though this did not affect overall mortality.

Endovascular aneurysm repair: a perioperative perspective

Endovascular aneurysm repair (EVAR), has surpassed open repair as the technique of choice in many centres in response to several large studies which showed significantly improved 30-day mortality. While several multicentre EVAR trials looked at surgical outcomes, very few have specifically investigated the effect of anaesthetic techniques or perioperative care of these patients. The purpose of this review to is to present some of the current evidence for the different aspects of perioperative management of patients undergoing EVAR. This includes surgical considerations, pre-operative assessment, and choice of anaesthetic technique as well as pharmacological protective strategies.

Novel uses for statins in surgical patients

BACKGROUND

Aside from their cholesterol-lowering effects statins are known to have a range of other 'pleiotropic' effects. We present an overview of the basic science behind these effects and then review clinical trials and the current role of statins relevant to modern surgical practice.

METHODS

A systematic review of the literature was performed using the keywords surgery and the MeSH term for statins. All clinical studies relating to statin use in surgical patients were evaluated. An overview of the literature on statin use and cardiac outcomes was performed.

CONCLUSIONS

Statins are safe and have a wide range of pleiotropic effects relevant to surgical practice. Strongest evidence for their clinical use comes in primary cardiac risk reduction in many types of vascular surgery. There is a large body of evidence showing their benefit perioperatively in high-risk vascular and cardiac surgery but the picture is less clear for low-risk patients. Further studies are needed to evaluate exact dosage regimes and timing of administration. Novel uses of their anti-inflammatory properties in sepsis and vasomotor properties in subarachnoid haemorrhage are being further investigated by randomised trials.