SHAPE Society

1. Statins are associated with aStatins are associated with a
reduced incidence of perioperativereduced incidence of perioperative
mortality in patients undergoingmortality in patients undergoing
major vascular surgerymajor vascular surgery
Poldermans D, Bax JJ, Kertai MD,
Krenning B, Westerhout CW, Schinkel AF, Thomson
IR, Lansberg PJ, Fleisher LA, Klein J, van Urk H,
Roelandt JRTC, Boersma E
Erasmus MC, Departments of Cardiology and
Anaesthesiology

2. Increased plaque rupture and thrombus formation
due to the stress response to surgery on
hemodynamically (in)-significant coronary stenosis
hemodynamic stress, vasospasm, fibrinolytic activity,
platelet activation, hypercoagulability
Sustained ischemia
myocardial supply : demand - mismatch
Pathophysiology of perioperative MIPathophysiology of perioperative MI
Poldermans et al., Circulation 2003; 107: 1848-1851

3. Perioperative cardiac risk managementPerioperative cardiac risk management
Beta-blockers
reduction in perioperative cardiac death and MI
Alpha 2 – adrenergic agonists
Mivazerol associated with a lower incidence of
MI and death from cardiac causes
Nitroglycerin/diltiazem
lack of sufficent evidence about their beneficial
effect
Coronary reavscularization
is appropriate if indicated independently of the
need for surgery
Poldermans et al., Circulation 2003; 107: 1848-1851

4. 1065 patients underwent elective major vascular surgery
between 1989-2001 at the EMCR
Inclusion criteria:
preoperative DSE, died within 30 days after surgery,
autopsy
DSE: presence and location of ischemia LAD / LCX /
RCA territory
Location of MI at autopsy
Can dobutamine echocardiographyCan dobutamine echocardiography
predict the location of perioperativepredict the location of perioperative
infarction?infarction?
Poldermans et al., Circulation 2003; 107: 1848-1851

5. Patients N = 32
Preoperative ischemia in 16 patients, in 7 (44%) in more
than one coronary territory
All patients experienced cardiac death
MI was located outside the territory at risk defined by DSE
in 8 /16 (50%) patients
Can dobutamine echocardiographyCan dobutamine echocardiography
predict the location of perioperativepredict the location of perioperative
MI?MI?
Poldermans et al., Circulation 2003; 107: 1848-1851

6. BackgroundBackground
Patient undergoing major vascular surgery
are at increased risk of perioperative mortality
due to underlying coronary artery disease
Inhibitors of the 3-hydroxy-3-methylglutaryl
coenzyme A (statins) may reduce
perioperative mortality through the
improvement of lipid profile
through the stabilization of coronary
plaques on the vascular wall
Poldermans et al., Circulation 2003; 107: 1848-1851

7. AimAim
To evaluate the association between statin
use and perioperative mortality in patient
undergoing major vascular surgery
Poldermans et al., Circulation 2003; 107: 1848-1851

8. Study DesignStudy Design
• retrospective case-control study among of
2816 patients aged 18 years or older
• scheduled for acute or elective abdominal
aortic repair, carotid endarterectomy, or lower
extremity revascularization
Poldermans et al., Circulation 2003; 107: 1848-1851

9. Selection of cases and controlsSelection of cases and controls
• cases: 160 patients who died due to any
cause during surgery or during the hospital
stay following surgery
controls: two per each case; patients who were
operated immediately before and after the
case, stratified according to type of surgery,
calendar year
Poldermans et al., Circulation 2003; 107: 1848-1851

10. Data CollectionData Collection
• information on
cardiac risk factors (diabetes mellitus, angina
pectoris, myocardial infarction, heart failure,
renal failure, stroke)
the most recent measurements of total and
LDL cholesterol within 3 months prior to
surgery
Poldermans et al., Circulation 2003; 107: 1848-1851

11. Results – Table 1Results – Table 1
Characteristics Cases
(N=160), [%]
Controls
(N=320), [%]
P-Value
Age 72 (66-77) 69 (62-75) <0.001
COPD 58 (36) 64 (20) <0.001
Renal failure 34 (21) 37 (12) 0.005
Angina pectoris 55 (34) 76 (24) 0.01
Myocardial infarction 84 (53) 109 (34) <0.001
Heart failure 44 (28) 35 (11) <0.001
Stroke 35 (22) 29 (9) <0.001
Type of surgery 1.0
Poldermans et al., Circulation 2003; 107: 1848-1851

12. Complications during theComplications during the
perioperative phaseperioperative phase
• Vascular complications n=104 (65%)Vascular complications n=104 (65%)
fatal MI n=88 (56%)
fatal stroke n=14 (9%)
• Non-vascular complicationsNon-vascular complications
bleeding n=21 (13%)
sepsis n=30 (19%)
Poldermans et al., Circulation 2003; 107: 1848-1851

13. Statin use in relation to mortalityStatin use in relation to mortality
0%
20%
40%
60%
80%
100%
Cases Controls
Odds Ratio = 0.22 (0.10-0.47)
Statin users
Non-users
Poldermans et al., Circulation 2003; 107: 1848-1851

14. Beta-blocker use in relation toBeta-blocker use in relation to
mortalitymortality
0%
20%
40%
60%
80%
100%
Cases Controls
Odds Ratio = 0.43 (0.26-0.72)
Beta-blocker use
Non-users
Poldermans et al., Circulation 2003; 107: 1848-1851

15. Perioperative mortality in relation toPerioperative mortality in relation to
statin usestatin use
0.01 0.1 1 10
No. of risk factors
0 or 1
2
3 or more
Beta-blocker use
No
Yes
Poldermans et al., Circulation 2003; 107: 1848-1851

16. ConclusionsConclusions
• statin use reduced perioperative mortality
• patients on statin therapy had a more than
four-fold reduced risk
• the results were consistent regardless of the
type of surgery, cardiac risk factors, and beta-
blocker use
Poldermans et al., Circulation 2003; 107: 1848-1851