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Clonidine and Aspirin Fail to Reduce Peri-operative Myocardial Infarction

29 Jun, 14 | by Alistair Lindsay

Myocardial infarction (MI) is the most common major vascular event that occurs after planned non-cardiac surgery.  Multiple strategies have been assessed to try and reduce the rates of peri-operative MI, but few have consistently demonstrated substantial benefit.  With a pro-thrombotic environment and marked sympathetic activation thought to play etiological roles, in the POISE-2 study, the antiplatelet agent aspirin and the alpha-agonist clonidine, were studied in a 2×2 factorial design.   A total of 10,010 patients were randomized in this multi-center, international study to receive a combination of aspirin and clonidine or corresponding placebo.  The trial results from both arms were reported separately, but both arms of the study were neutral for the primary composite outcome of death or nonfatal myocardial infarction at 30 days. The 30-day event rate was 7.0% in patients treated with aspirin and 7.1% in the placebo group (HR, 0.99; 95% CI, 0.86 to 1.15; P=0.92).   Among patients treated with clonidine, 6.6% suffered an event at 30-days compared with 5.9% in the placebo group (HR, 1.11; 95% CI, 0.95 to 1.30; P=0.18).  Aspirin significantly raised the risk of major bleeding (P=0.04) and clonidine increased the risk of clinically significant hypotension (P<0.001). more…

β-blockers beneficial in some, but not all, ischemic heart disease patients undergoing non-cardiac surgery

8 Jun, 14 | by Alistair Lindsay

Whether β-blockers reduce adverse events among patients with stable ischemic heart disease (IHD) undergoing non-cardiac surgery remains in debate. In this Danish study, the authors retrospectively identified 28,263 IHD patients who underwent non-cardiac surgeries and examined the association between pre-procedural β-blockers use and a major adverse cardiovascular event (MACE) defined as 30-day cardiac death, myocardial infarction (MI) and stroke. The cohort included 7,990 patients (28.3%) with heart failure and 12,601 (44.6%) with a history of MI.  Overall, 1,374 (4.9%) experienced a MACE. The risk for MACE was lower among patients treated with β-blockers in the setting of a history of heart failure (adjusted hazard ratio [HR] 0.78; 95% confidence interval [CI] 0.66-0.91) but not among patients without heart failure (adjusted HR 1.11; 95% CI 0.92-1.13). Among patients without heart failure, use of β-blockers was associated with lower risk of MACE in patients with an MI in the prior 2 years (HR 0.54; 95% CI 0.37-0.78). more…

Stent type and interrupted anti-platelet therapy does not correlate with adverse events after non-cardiac surgeries

29 Dec, 13 | by Alistair Lindsay

Guidelines recommend delaying elective surgery in patients with drug eluting stent (DES) for one year after stent implantation to allow completion of 1 year of dual anti-platelet therapy (DAPT) without interruption.  This recommendation is based on expert consensus and results in several clinical questions, including whether it is preferable to use a bare metal stent (BMS) in patients with a potential for future surgery and whether this delay is excessive for patients considering surgery with other potential benefits (i.e. knee replacement in patients with life-limiting osteoarthritis).  Accordingly, the authors sought to understand the risk of major adverse cardiovascular events (MACE) following non-cardiac surgery among patients with coronary stents as a function of time since coronary stenting, stent type, and antiplatelet therapy during surgery. more…

Beta-blockers could increase risk in noncardiac surgery

17 Jan, 09 | by Alistair Lindsay

Many trials have suggested a protective role for beta-blockade in noncardiac surgery, and the current ACC/AHA guidelines recommend their use in high-risk patients.  However, preliminary results from the recent POISE (Perioperative Ischemic Evaluation (POISE) trial showed a higher incidence of total deaths and stroke in patients receiving peri-operative bera-blockade compared with placebo. more…

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