In the Literature: March 2010

The Hospitalist. 2010 March;2010(03):

March 1, 2010|The Hospitalist

Richard Quinn

In This Edition

Literature at a Glance

A guide to this month’s studies

Statins and postoperative cardiac outcomes
Cardiac resynchronization therapy in patients with mild CHF symptoms
Oral direct thrombin inhibitor versus warfarin for stroke prevention in atrial fibrillation
Association of fatigue and medical error
Effects of chronic inhaled steroid and beta-agonist use in COPD
Dialysis and functional status in nursing home patients
Outcomes with different insulin-dosing regimens
Understanding of disease severity and outcomes in advanced dementia

Clinical Shorts

BILATERAL TOTAL KNEE ARTHROPLASTY IS ASSOCIATED WITH A GREATER PERIOPERATIVE RISK THAN A UNILATERAL PROCEDURE

Analysis of a large administrative database showed that patients with bilateral total knee arthroplasties (TKAs) had higher complication rates and inpatient mortality than with unilateral. Staged bilateral procedures were no safer than simultaneous.

Citation: Memtsoudis SG, Ma Y, Gonzalez Della Valle A, et al. Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology. 2009;111(6): 1206-1216.

Fluvastatin Improves Postoperative Cardiac Outcomes in Patients Undergoing Vascular Surgery

Clinical question: Does perioperative fluvastatin decrease adverse cardiac events after vascular surgery?

Background: Patients with atherosclerotic vascular disease who undergo vascular surgery are at high risk for postoperative cardiac events. Studies in nonsurgical populations have shown the beneficial effects of statin therapy on cardiac outcomes. However, no placebo-controlled trials have addressed the effect of statins on postoperative cardiac outcomes.

Study design: Randomized, double-blind, placebo-controlled trial.

Setting: Single large academic medical center in the Netherlands.

Synopsis: The study looked at 497 statin-naïve patients 40 years or older undergoing non-cardiac vascular surgery. The patients were randomized to 80 mg of extended-release fluvastatin versus placebo; all patients received a beta-blocker. Therapy began preoperatively (median of 37 days) and continued for at least 30 days after surgery. Outcomes were assessed at 30 days post-surgery.

Postoperative myocardial infarction (MI) was significantly less common in the fluvastatin group than with placebo (10.8% vs. 19%, hazard ratio (HR) 0.55, P=0.01). In addition, the treatment group had a lower frequency of death from cardiovascular causes (4.8% vs. 10.1%, HR 0.47, P=0.03). Statin therapy was not associated with an increased rate of adverse events.

Notably, all of the patients enrolled in this study were high-risk patients undergoing high-risk (vascular) surgery. Patients already on statins were excluded.

Further studies are needed to determine whether the findings can be extrapolated to other populations, including nonvascular surgery patients.

Bottom line: Perioperative statin therapy resulted in a significant decrease in postoperative MI and death within 30 days of vascular surgery.

Citation: Schouten O, Boersma E, Hoeks SE, et al. Fluvastatin and perioperative events in patients undergoing vascular surgery. N Engl J Med. 2009;361(10):980-989.

Clinical Shorts

INTENSITY OF CONTINUOUS RENAL-REPLACEMENT THERAPY IN CRITICALLY ILL PATIENTS HAS NO EFFECT ON MORTALITY

This prospective, multicenter, randomized trial failed to show differences in 90-day mortality and other outcomes between high and low (40 mg/kg vs. 25 ml/kg effluent flow, respectively) continuous renal-replacement therapy (CRRT) in critically ill patients.

Citation: RENAL Replacement Therapy Study Investigators, Bellomo R, Cass A, et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009; 361(17):1627-1638.

Cardiac Resynchronization Therapy with Implantable Cardioverter Defibrillator Placement Decreases Heart Failure

Clinical question: Does cardiac resynchronization therapy (CRT) with biventricular pacing decrease cardiac events in patients with reduced ejection fraction (EF) and wide QRS complex but only mild cardiac symptoms?

Background: In patients with severely reduced EF, implantable cardioverter defibrillators (ICDs) have been shown to improve survival. Meanwhile, CRT decreases heart-failure-related hospitalizations for patients with advanced heart-failure symptoms, EF less than 35%, and intraventricular conduction delay. It is not as clear whether patients with less-severe symptoms benefit from CRT.